TSBC TRIPLE T REGISTRATION FORM

Every Thursday, June 9 July 14

10:00 AM to 12:00 PM
For Children 4 years old up to finished 5 th Grade
PARTICIPANT INFORMATION
PARTICIPANT'S NAME

DATE OF BIRTH

DATE OF REGISTRATION

ADDRESS STREET

CITY

STATE

LAST GRADE COMPLETED

ZIP

PERMISSION TO BE PHOTOGRAPHED:
YES
NO

PARENT/GUARDIAN INFORMATION
PARENT/GUARDIANS NAME

HOME PHONE

CELL PHONE

MOMS PLACE OF EMPLOYMENT

EMPLOYMENT ADDRESS

WORK PHONE

DADS PLACE OF EMPLOYMENT

EMPLOYMENT ADDRESS

WORK PHONE

IF PARENT/GUARDIAN CANNOT BE REACHED

PLEASE CONTACT:

PHONE NUMBER

WHO IS AUTHORIZED TO TRANSPORT PARTICIPANT

PHONE NUMBER

RELATIONSHIP TO
PARTICIPANT:

MEDICAL INFORMATION
PLEASE LIST ANY ALLERGIES (INCLUDING FOOD ALLERGIES) PHYSICAL CONDITION, DEFECTS, OR MEDICAL
CONDITIONS THAT WOULD LIMIT PARTICIPANT FROM PARTICIPATING:

MEDICAL/WAIVER/RELEASE OF RESPONSIBILITY
I ACKNOWLEDGE, UNDERSTAND, AND ASSUME ALL RISKS INVOLVED IN ANY ACTIVITIES ON THE PREMISES OF
TUMBLING SHOALS BAPTIST CHURCH. I FURTHER AGREE TO HOLD HARMLESS TUMBLING SHOALS BAPTIST
CHURCH, THE VOLUNTEERS OR STAFF TEACHERS, FROM ANY AND ALL CLAIMS, SUITS, LOSSES,
OR DAMAGES OF ANY NATURE WHAT SO EVER, INCLUDING BUT NOT LIMITED TO, SUCH CLAIMS THAT MAY
RESULT FROM MY CHILD'S INJURY OR DEATH, WHETHER IT BE ACCIDENTAL AS A RESULT OF NEGLIGANCE OR
OTHERWISE, DURING OR ARISING IN ANY WAY FROM SUMMER PROGRAM ACTIVITIES.
I HEREBY GRANTPERMISSION TO LICENSED HOSPITAL AND/OR STAFF MEMBERS TO ADMINISTER IMMEDIATE
MEDICAL TREATMENT AS DEEMED NECESSARY TO MY CHILD SHOULD HE/SHE BE INJURED DURING ANY
EVENT HE/SHE LEFT IN THE CARE OF TUMBLING SHOALS BAPTIST CHURCH VOLUNTEERS OR STAFF.
FURTHER, I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF EXPENSES INCURRED RELATING TO MY
CHILD'S MEDICAL TREATMENT.
PARENT/GUARDIAN SIGNATURE

DATE