Registration Form 2019/20

2020/21 MOPS Registration

Home Church (leave blank if not applicable)

Today's Date

Mother's Birthday

Phone Type

Cell

Home

Other

Marital Status:

Married

Single

Street Address

City

State

Zip

Spouse/Significant Other

Spouse/Significant Other Phone

Alternate Emergency Contact (authorized to act on behalf of parent(s)/legal guardian):

Emergency Contact Primary Phone

Phone Type

Cell

Home

Emergency Contact Alternate Phone

Emergency Contact Relationship To Child

Children's Information

Please only include children who will be participating in the MOPS Kids Program

Child #1

Child's Legal Name (only include last name if different from Mother's listed above)

Nickname/Preferred Name (if none, leave blank)

Child's Birthday

Child's Age as of September 1

Allergies/Known Medical Conditions

Child #2

Child's Legal Name (only include last name if different from Mother's listed above)

Nickname/Preferred Name (if none, leave blank)

Child's Birthday

Child's Age as of September 1

Allergies/Known Medical Conditions

Child #3

Child's Legal Name (only include last name if different from Mother's listed above)

Nickname/Preferred Name (if none, leave blank)

Child's Birthday

Child's Age as of September 1

Allergies/Known Medical Conditions

Child #4

Child's Legal Name (only include last name if different from Mother's listed above)

Nickname/Preferred Name (if none, leave blank)

Child's Birthday

Child's Age as of September 1

Allergies/Known Medical Conditions

Children's Medical Insurance Information

For use in medical emergencies only

Medical Insurance Provider

Group #

ID #

Phone

Employee

Employer

Employer Phone

Other necessary information for Medical Personnel

AUTHORIZATION AND WAIVER FORM:

I authorize above listed child/ren to participate in Faith Baptist Church (the Church) Children’s Program, including any transportation provided by the Church for the activity for the current school year. If the parent or guardian cannot be contacted at the phone number(s) listed above, I give any leader of the activity permission to authorize any medical treatment that may be reasonably necessary for the participant and give permission to the attending physician, dentist, or other health care provider to provide such treatment. I agree that my medical insurance plan is the primary plan to pay any medical treatment given to the participant.

WAIVER. I understand that while the Church will take reasonable precautions, the activity (including any transportation provided for the activity) involves the possibility of unforeseeable risks. In exchange for the Church allowing the participant to participate in the activity, I waive and I release and discharge the Church, their related ministries and organizations, and each of their elders, directors, officers, managers, employees, volunteers, members, and agents from any and all claims, losses, or expenses arising from or related to the activity. I also agree to indemnify, hold harmless, Kent MOPS | MOMSnext Mothers of Preschoolers 25636 140th Avenue SE | Kent, WA 98042 253.631.0990 | www.faithkent.org and defend the Church and each of the other parties listed above with regard to such claims, losses or expenses, including without limitation any claims made by or on behalf of the participant.

I HAVE READ AND FULLY UNDERSTAND THIS FORM. I UNDERSTAND THAT I AM WAIVING AND RELEASING ANY CLAIMS.

By registering your child, you give us permission to use photos or videos captured by our staff that may include your child for use by Faith Baptist Church.

Participant less than 18 years-old: Parent or guardian sign below. I understand and agree to be bound by the Authorization and Waiver and sign it both in my own capacity as parent or guardian and in a representative capacity on behalf of my child/ren.

I have read and fully understand this form. By checking this box I am virtually signing this document and agreeing to all terms and information.

Today's Date