Child's First Name

Child's Last Name

Grade

T-shirt Size

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Parent's First Name

Parent's Last Name

Phone Number

Email

Any allergies or special needs we need to be aware of?

Medical/Media Release:
I release, hold harmless North Shore Church, it’s employees and volunteers, from any and all liability for any harm to the child(ren) which results directly or indirectly from participation in the ministries and events of North Shore Church. If the Minor is injured while participating in North Shore Children’s Ministries or events and I am unable to provide consent to his or her medical treatment, I authorize the Church to consent on my behalf to the performance of any and all medical treatment deemed necessary until I am able to provide consent or until someone legally able to speak on the Minor’s behalf is made available. I agree to pay or arrange for payment for all costs associated with said medical treatment. I hereby authorize North Shore Church to use and reproduce audio and/or video recording and representation of me and/or my children which the organization has obtained and understand that these images may be used in North Shore Church promotional materials.

Medical/Media Release

I agree

Signature