Kidz Kaboom Online Registration Form

CHILD INFO

Child's Last Name:   Child's First Name:    Child's Middle Initial:

Gender:    Grade (08-09 school year):

Date of Birth (month / day / year):

PARENT'S INFO

Father's Last Name:   Father's First Name:

Father's Email:

Mother's Last Name:   Mother's First Name:

Mother's Email:

Primary Guardian(s) Address: 

City:     State:      Zip: 

Home Phone:      Cell Phone:

Would you be willing to help assist with Kidz Kaboom? 

Church (if you regularly attend church, which one?)

Shirt Size:

Elementary Kids list your top 3 choices in camp activities (chose from basketball, cheerleading, dance, art, cooking, martial arts.)
If your first choice of activity is unavailable, you will be contacted with an alternative camp option.
ALL CHILDREN WHO HAVE NOT YET COMPLETED KINDERGARTEN MUST SELECT THE PRESCHOOL CAMP
First choice:      
Second choice:
Third choice:     

EMERGENCY CONTACT INFO

Last Name:   First Name:

Home Phone:      Cell Phone:


HEALTH INFO

Specific Allergies:

Any Medications:
(Please inform registration personnel of any prescription medication needed)

Primary Care Physician
                                Phone

Insurance Company
                          Phone

Name Insurance is listed under
Policy No.
Group No.

If there is any other information that you would like to share about your child, please let us know:



RELEASE OF LIABILITY

AFTER READING CAREFULLY, PLEASE SELECT THE RELEASE CHECK BOX BELOW TO INDICATE YOUR AGREEMENT.
NOTE: THIS FORM INCLUDES A RELEASE OF LIABILITY
Please review and complete the check box below to indicate your agreement with all statements made below.

AUTHORIZATION AND RELEASE OF LIABILITY

I, the parent or guardian of the above-named child, authorize the participation of my child in the Kidz Kaboom athletic
program (the “Program”) of Allison Park Church. My child will participate in the Kidz Kaboom activities denoted on this brochure.
I understand that this Program is a nonprofit Christian sports ministry program for youth and that my child’s participation is
voluntary and not essential to completion of requirements of any program, school or government agency. I understand that
the Program is conducted by the Church and its volunteers and staff, including parents of other participating children. I also
understand that the Church is solely responsible for all aspects of the Program including selection and supervision of all
persons conducting the Program, and that Upward Unlimited is not responsible for the Program or selecting and supervising
persons conducting the Program. I further understand and agree that my child’s participation in athletic and other activities
of the Program necessarily involves the risk of injury and even death from various causes, including but not limited to
accidents, falls, strenuous and prolonged physical activity, dehydration, illness, collision or dispute with other participants,
weather related injuries, playing area and equipment defects, and negligence of coaches and referees. On behalf of my
child, me, and my family, I assume these risks.

In consideration of the privilege of my child’s participation in the Program, and on behalf of my child and me as parent/
guardian, I hereby release, discharge, hold harmless and indemnify, and covenant not to sue, the Church and Kidz Kaboom,
and all of the Church’s and Kidz Kaboom’s directors, officers, elders, trustees, deacons, employees,
volunteers, insurers, agents and representatives, and all other persons associated with the Program (including without
limitation any other participating churches, sponsors, parents, vendors, coaches and other game and event workers,
officials, drivers, and organizations) as to any and all claims of my child, me and other family members for personal injuries
suffered by my child, property damage, medical expenses, and economic loss arising directly or indirectly out of my child’s
participation in the Program, and any first aid, medical care or treatment provided to my child in the event my child is injured
or becomes ill while participating in Program activities, and excepting claims that may not be released under applicable law.

This Release of Liability shall be as broadly construed as allowed by law to include all claims and rights that the child, that
I as parent/guardian, and that other family members may have. I am a legally responsible parent or guardian of my child.
If any provision of this Release of Liability is deemed invalid, the remaining provisions shall remain in full force and effect.
This Release of Liability shall be binding on me, my family, heirs, next of kin, legal representatives, beneficiaries, successors
and assigns. I give permission for free use of my child’s name and picture in photos, broadcasts, telecasts or written
accounts for any participation in a Kidz Kaboom sponsored event.

MEDICAL CONDITIONS
I understand that participation in the Program may involve strenuous and prolonged physical activity. I agree that my child
is healthy and able to participate in the Program activities.

I understand that the Church or its representatives may request health information concerning my child and/or ask my child
to undergo a medical exam. If the Church determines that my child does have a physical or mental condition that may affect
his/her ability to safely and appropriately participate in Program activities, the Church may determine that my child cannot
be permitted to participate. I understand and agree that, while the Church desires that all children will be able to participate,
such decisions may have to be made out of concern for the best interests of my child and other participants.

CONSENT TO MEDICAL TREATMENT
In the event my child is injured or becomes ill in Program activities, and if I, the parent or guardian of the above-named child,
am not present to make medical decisions, I hereby authorize the Church, its staff, volunteers including volunteer parent
participants, coaches, assistant coaches, and referees, supervisors and drivers, to arrange for and consent on my behalf
to emergency medical and dental care and treatment, including tests and radiological exams, and surgery, and hospital
care and treatment, and to consent to medications for pain and other conditions as prescribed by medical personnel
attending my child. I am responsible for payment of any medical charges or expenses not covered by my insurance or the
insurance applicable to my child (if any).

By my selecting yes to the check box below, I am therefore providing my authorized signature and I am indicating that all
information provided in this form is true and accurate, and that I fully agree to all statements made on the form, including but
not limited to the Authorization and Release of Liability, Medical Conditions, and Consent to Medical Treatment.
Each responsible parent/guardian should sign.

 YES, BY TYPING MY INITIALS IN THE FIELD BELOW, I RELEASE ALL LIABILITY