EmailMe Form - YOUTH MINISTRIES ENROLLMENT FORM

PLEASE READ DETAILS BELOW.

This ONE-TIME enrollment is REQUIRED PRIOR to your child(ren) being able to attend.

*THIS IS A ONE-TIME ENROLLMENT. WEEKLY REGISTRATION IS NOT REQUIRED.

*COMPLETING THE ENROLLMENT FORM DOES NOT GUARANTEE WEEKLY ATTENDANCE.

*CHILDREN WHO ARE ILL WILL NOT BE PERMITTED TO ATTEND.

Membership Status *

Member

Guest

1st Time Visitor

Adult 1 Name *

First Last

Relationship to Child *

Adult 1 Cell # *

### - ### - ####

Adult 1 Email *

Address *

Street Address City State / Province / Region Postal / Zip Code

Adult 2 Name

First Last

Relationship to Child

Adult 2 Cell #

### - ### - ####

Adult 2 Email

Address [of 2nd parent/guardian, if different]

Street Address City State / Province / Region Postal / Zip Code

Child 1 Name: *

First Last

Gender: *

Male

Female

Birthdate: *

MM / DD / YYYY

School Name: *

Current Grade:
(If your child is below 1st grade, please input '0' and choose from the list to the right: *

Level:

Infant/Nursery

Pre-K

Kindergarten

Please list any allergies or special needs your child has. If none, please enter n/a. *

Child 2 Name:

First Last

Gender:

Male

Female

Birthdate:

MM / DD / YYYY

School Name

Current Grade:
(If your child is below 1st grade, please input '0' and choose from the list to the right:

Level:

Infant/Nursery

Pre-K

Kindergarten

Please list any allergies or special needs your child has. If none, please enter n/a.

Child 3 Name:

First Last

Gender:

Male

Female

Birthdate:

MM / DD / YYYY

School Name

Current Grade:
(If your child is below 1st grade, please input '0' and choose from the list to the right:

Level:

Infant/Nursery

Pre-K

Kindergarten

Please list any allergies or special needs your child has. If none, please enter n/a.

Child 4 Name:

First Last

Gender:

Male

Female

Birthdate:

MM / DD / YYYY

School Name

Current Grade:
(If your child is below 1st grade, please input '0' and choose from the list to the right:

Level:

Infant/Nursery

Pre-K

Kindergarten

Please list any allergies or special needs your child has. If none, please enter n/a.

Child 5 Name:

First Last

Birthdate:

MM / DD / YYYY

Gender:

Male

Female

School Name

Current Grade:
(If your child is below 1st grade, please input '0' and choose from the list to the right:

Level:

Infant/Nursery

Pre-K

Kindergarten

Please list any allergies or special needs your child has. If none, please enter n/a.

Child 6 Name:

First Last

Gender:

Male

Female

Birthdate:

MM / DD / YYYY

Current Grade:
(If your child is below 1st grade, please input '0' and choose from the list to the right:

School Name

Level:

Infant/Nursery

Pre-K

Kindergarten

Please list any allergies or special needs your child has. If none, please enter n/a.

MEDIA RELEASE AND CONSENT -

This section is for Word of Restoration advertisement such as announcements, graphics, activities, flyers, etc.

This consent authorizes Word of Restoration International Church and those acting pursuant to its authority, or with its permission, to interview and/or to have photographs, audio or audiovisual recordings made of the above-named minor(s) (“Media Images”). I waive any right to inspect the uses of any printed or electronic copy. I further acknowledge that I will not be compensated for these uses and Word of Restoration International Church owns all rights to the images, videos, and recordings, and to any derivative works created from them. I hereby release Word of Restoration International Church and its agents and assigns from any and all liability connected with the capture or use of these Media Images. This Release expresses the complete understanding of the parties.

MEDIA RELEASE AND CONSENT *

I authorize the use of Media Images of my child(ren).

I DO NOT authorize the use of Media Images of my child(ren).

RELEASE AND WAIVER OF LIABILITY

My minor child, or a minor child under my legal guardianship (individually and collectively referred to as Participants), intend to participate in the following activity (“Activity”) of Word of Restoration International Church: Youth and Children's Ministry.

Participants release and forever discharge and hold harmless Word of Restoration International Church and its Directors, officers, employees, agents, attorneys, related entities, successors, and assigns (collectively, WORIC) from any and all liability, claims, and demands of any kind or nature, either in law or in equity, which exist now or in the future in connection with Participants’ participation in the Activity. Participants understand and agree that this Release discharges WORIC from any liability or claim that Participants may have against WORIC with respect to bodily injury, personal injury, illness, death, property damage, or any other harm that may result from Participants’ participation in the Activity. Participants expressly waive any right to a trial by judge or jury that Participants may otherwise have with regard to any claim or liability related to Participants’ participation in the Activity.

RELEASE AND WAIVER OF LIABILITY *

I have read, understand, and give my consent to the statement above.

I have read, understand and DO NOT give my consent to the statement above. Selecting this option will void enrollment.

RELEASE AND WAIVER OF LIABILITY ACKNOWLEDGEMENT:
READ CAREFULLY BEFORE SIGNING

By my signature below, I acknowledge that I have read this release and waiver of liability in its entirety and, in consideration for the right of myself and my minor child or a minor child under my legal guardianship to participate in the Activity, I, in good faith make the releases and waivers and assume the responsibilities contained herein. I acknowledge that I have had an opportunity to ask questions and consult with an attorney of my choosing, and that I freely agree to the terms expressed in return for participation in the Activity.

Parent/Guardian Signature *

Clear

Parent/Guardian Name *

First Last

Additional Parent/Guardian Signature (optional)

Clear

Additional Parent/Guardian Name (optional)

First Last

PLEASE READ DETAILS BELOW.

MEDIA RELEASE AND CONSENT - This section is for Word of Restoration advertisement such as announcements, graphics, activities, flyers, etc.

RELEASE AND WAIVER OF LIABILITY

RELEASE AND WAIVER OF LIABILITY ACKNOWLEDGEMENT: READ CAREFULLY BEFORE SIGNING

MEDIA RELEASE AND CONSENT -

This section is for Word of Restoration advertisement such as announcements, graphics, activities, flyers, etc.

RELEASE AND WAIVER OF LIABILITY ACKNOWLEDGEMENT:
READ CAREFULLY BEFORE SIGNING