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Prime Time After-School Care Registration
Child First Name
Child Last Name
Child's Age
Grade
Parent/Guardian First Name
Parent/Guardian Last Name
Email
Address 1
Address 2
Country
City
State
Zip/Postal Code
Home Phone Number
Parent/Guardian Cellphone Number
Alternate Contact/Caregiver First Name
Alternate Contact/Caregiver Last Name
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Phone Number
Early/Alternate Pick-Up First Name
Early/Alternate Pick-Up Last Name
Allergies or Medical Conditions
Additional Medical/Emotional Needs or Physical Limitations
Additional Comments
I hereby consent & certify that my child named above is able to participate in all the program and activities involved with Prime Time. I realize my child will participate in activities in conjunction with other persons. I accept full responsibility for my child’s actions, injuries to self or other persons, and damage to personal or church property. I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITY, INCLUDING ACTIVITIES PRELIIMINARY AND SUBSEQUENT THERE TO. I do hereby agree to hold Union Baptist Church and its agents and employees, and volunteers harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Vermont and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.
I do consent
I do not consent
We recognize the need to ensure the welfare and safety of all young people taking part in any activity associated with our organization. In accordance with our child protection policy we will not permit photographs, video or other images of young people to be taken without the consent of the parents/caregivers and children. As your child will be taking part in the event specified above, we would like to ask for your consent to take photographs/videos of the event or activity that may contain images of your child. It is likely that these images may be used as: A record of the activity or the event OR publicity material for further activities or events on leaflets/websites/magazines We will take all steps to ensure these images are used solely for the purposes they are intended. If you become aware that these images are being used inappropriately you should inform us immediately.
I consent to having my child photographed or recorded for this event.
I do not consent to having my child photographed or recorded for this event
*** I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE BELOW AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.***
Electronic Signature
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