• First Name *
• Last Name *
• Grade 2009-2010 school year *PreK Kindergarten1st Grade 2nd Grade3rd Grade 4th Grade5th Grade
• Gender * Male Female
• Age *
• Date of Birth (mm/dd/yyyy) *
• Street Address *
• City *
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• Zip *
• Child's email 
• Child's Phone 
• School Name *
• School Phone *
• Parent/Guardian 1 Name *
• Parent/Guardian 1 Home Phone *
• Parent/Guardian 1 Work Phone *
• Parent/Guardian 1 Cell Phone *
• Parent/Guardian 1 Email *
• Parent/Guardian 2 Name 
• Parent/Guardian 2 Home Phone 
• Parent/Guardian 2 Work Phone 
• Parent/Guardian 2 Cell Phone 
• Emergency Contact Name *
• Emergency Contact Home Phone *
• Emergency Contact Work Phone *
• Emergency Contact Cell Phone *
• Doctor's Name *
• Doctor's Phone *
• Doctor's address(city) *
• Allergies *
• Other medical/behavioral conditions *
• Medical Insurance Company *
• Policy # *
• Home Church *
• Please select:*
  Yes, you have my permission to display photos taken of my child during the above children's ministry event.
  No, please do not display photos of my child taken during the above children's ministry event.

The following terms and conditions apply to Monticello United Methodist Church children's ministry events between September 2009 and May 31, 2010.

As the parent or guardian of this participant, I hereby release, waive, discharge and agree to hold harmless the Monticello United Methodist Church, its agents, officers, employees, and volunteers from all liability to me, my spouse, or my child for any and all loss and personal injury, including injury resulting in death, unless the damage and personal injury has been caused by the gross negligence of the agents, officers, employees or volunteers of the Monticello United Methodist Church.

I understand that accidents can occur. If first aid is required, it may be provided by church staff prior to the arrival of emergency personnel. I also consent to emergency medical treatment, hospitalization, or other medical treatment as may be necessary for the welfare of my child by a physician, qualified nurse, and/or hospital, in the event of injury or illness during all periods of time in which the student is away from his/her legal residence as a member of this church sponsored group. I hereby waive on behalf of myself, spouse and the above-named child any liability of the church and of its agents or employees arising out of such medical treatment.
I have read and accept the above terms and conditions:
Registration will not be accepted unless this box is checked.

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• Submit box disabled unless terms and conditions accepted