Child(ren) name(s) *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Signature box *

By checking the signature box, you give permission for the child(ren) named above to take part in the Children’s Summer Program at Timberlea Baptist Church. Further, you understand that while involved, they will be taken under the supervision and care of adults and church staff approved by the church. Leaders will take all reasonable care of the children, though cannot be held responsible for loss, damage or injury suffered by your child, during or because of the Children’s Summer Program. By checking the box, you allow Timberlea Baptist Church personnel to seek medical attention that may be necessary in emergency situations should they be unable to contact parents/guardians and herby consent to any medical treatment or care deemed necessary by medical personnel. Further, you agree that Timberlea Baptist Church, Church staff and Church volunteers are relieved of all liability in the event of accident or injury. Finally, by checking the box, you give consent for photographs of child(ren) named above to be used as promotional materials for Summer Children’s Program. Thank you for helping us take the best possible care of your child(ren) and we are excited for this program! If you have any questions, please contact Michaela Larade (mlarade14@gmail.com)

I Agree