(11-13 yr old registration) 2025 Christian Recreation Program

Name

Age

11 12 13

Most recent grade completed

4 5 6 7

Date of Birth

Address

Gender

Male Female

Food Allergies

Yes No

Types of Food Allergies (leave blank if none)

Other Allergies, Medical Conditions, Disabilities, etc. (leave blank if none)

Parent/Legal Guardian Information

Name

Emergency Phone #1

Emergency Phone #2

Pickup Authorization

THE FOLLOWING ADULTS ARE AUTHORIZED TO PICKUP MY CHILD FROM CRP

Under NO circumstances will the child be released to anyone other than those listed above without WRITTEN permission from the parent.

Acknowledged and Agreed

This address will receive a confirmation email

Name of Home Church

Program Authorization: I certify that I am a parent/legal guardian of the above listed child. The child listed above has my permission to participate in the Christian Recreation Program. By my checkmark, I release Gospel Fellowship Presbyterian Church, and any staff or volunteers of the Christian Recreation Program from any liability in the event of an accident or illness that may occur on the grounds or during any activity. In case of medical emergency, I give permission for emergency medical treatment to be given to my child as the result of accident or illness. I also hereby grant permission that images of my child may be captured and used for any legal use in our promotional materials, including our website, brochures, and the CRP slide show; without compensation to me by any reason of such use. To deny the photo release, please contact the church office.

Certified and Permission Granted

Medical Waiver and Agreement: I understand that as a religious service, CRP staff will not be enforcing mask regulations on individuals coming to the program and so I accept full responsibility for sending my children to the program each day. I agree that the precautions outlined are sufficient and I recognize that any public event increases risk of exposure to illness and accept the responsibility for that risk. I furthermore agree not to bring any of my children to the program while they are sick.

Acknowledged and Agreed

Donation

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

(11-13 yr old registration) 2025 Christian Recreation Program

Description

Please Fix the Following