Marketplace

July 14-18, 2008

Registration Form (Entering Kindergarten-Fifth Grade)

ChildŐs Name:

Grade (Fall 2008)             Age:            Gender:           ChildŐs Costume Size: Sm  Med  Lrg

Address:                                                               City:                                        Zip: 

Home Phone:                     Work Phone:                      Cell Phone:                                

Home Church:                                                                                                             

Emergency Name:                                 Relationship:                     Phone:                     

Who, other than the parent can pick up this child?                                                           

 

MEDICAL RELEASE

I hereby release, forever discharge and agree to hold harmless, Newport Mesa Church, its elders, directors, employees and volunteers, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above named child that occur during any activities. Furthermore, I hereby assume all risk and personal injury, sickness, death, damage and expense as a result of participation in these activities. The undersigned further agrees to hold harmless and indemnify Newport Mesa Church, its elders, directors, employees and volunteers, for any liability sustained by said church as the result of the negligent, willful or intentional acts of the above named child, including expenses incurred attendant thereto.

I,                                                          , parent or legal guardian of                                                                  herein authorize the adult sponsor of Newport Mesa Church to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, on the advice of any physician or surgeon licensed to practice in the state of treatment, when the need for such treatment is immediate, and when efforts to contact me are unsuccessful. This authorization is given pursuant to Section 25.8 of the Civil Code of California, and shall remain effective until July 18, 2008.

 

Signature                                                                                              Date                                                         

Physician                                                                       PhysicianŐs phone                                                         

Insurance Co.                                                                 Policy Number                                                              

Date of last tetanus shot                                             

Please list any medical conditions we should know about for the child:                                                              

                                                                                                                                                                             

Registration is final ONLY with payment and completed information.     

PRICE :$40 per child (LATE REGISTRATION $50 after July 6th)

Please make checks payable to NMC.

OFFICE USE ONLY:          Payment:  Check #                   Date Received