Child/Youth’s First & Last Name__________________________________________________
Age:_______ Grade:________ TShirt Size_____________ Date of Birth:___________________
Parent/Legal Guardian Information
First & Last Name______________________________________________________________
Home Address____________________________ City:___________________ State:________
Home Phone_______________ Cell Phone__________________ Work Phone___________
(In case of emergency and Parent/Guardian cannot be reached)
Name____________________________________________ Relation to child_______________
Medical Doctor_________________________________________ Phone__________________________
Does your child/youth have any medical conditions, allergies or other special needs?
If yes, please provide information:__________________________________________________
___Yes ____No I give Aldersgate United Methodist Church staff/volunteers permission to transport my child for the purpose of A.K.T.S. activities.
___Yes ___No I give permission for Aldersgate United Methodist Church staff/volunteers to arrange for emergency treatment if parent/guardian cannot be reached and it is necessary to preserve the health of my child until such time when I/we can be present. I understand that no guarantees have been made to me as to the effect of such treatment on my child’s condition. If necessary, the program will arrange for emergency transportation to the nearest emergency facility.
**Please note, Aldersgate United Methodist Church of Lincoln, Nebraska may on occasion take photographs and/or video of A.K.T.S. activities and participants for use in print materials or by electronic methods. Your entry into Aldersgate United Methodist Church, participation in Aldersgate United Methodist Church programs and activities grants permission for Aldersgate United Methodist Church of Lincoln, Nebraska to use these photographs and/or videos in its marketing and public relations efforts.
By signing below I give permission for my child to participate in program actvites. I understand that Aldersgate United Methodist Church does not carry health and accident insurance for my child/youth, and that I as guardian is primarily responsible in case of injury where bills are incurred. As parent/guardian I will work as a partner with staff/volunteers to ensure my child is successful in the A.K.T.S. program. The information I have listed is correct to the best of my knowledge and I will notify the church of any changes to the information in a timely manner.