KIDS & YOUTH REGISTRATION FORM

Parent Information

Parent First Name *

Parent Last Name *

Email Address *

Phone Number *

Relationship to Child(ren) *

Additional Parent/Guardian: First Name

Additional Parent/Guardian: Last Name

Additional Parent/Guardian: Phone Number

Additional Parent/Guardian: Relationship to Child(ren)

Street Address *

City *

State *

Ohio

Pennsylvania

Other (write in below) Other (write in below)

Zip Code *

I, the parent or official guardian of the child(ren) listed below, grant permission to Victory Church and its representatives, the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of my child for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium, including internet-based. I hereby release Victory Church and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my child’s statements that were given during an interview, with or without his/her name, for the purpose of advertising and publicity without restriction. I waive my child’s right to any compensation. All prints, videos, and digital reproductions shall be the property of Victory Church. *

Yes

No

If you answered Yes to the question above, please sign below.

clear

Child #1

First Name *

Last Name *

Birthdate * +

Gender *

Male

Female

Allergy or Medical Alert

Special Needs

Current Age or Grade this school year? *

Child #2

First Name (Child #2)

Last Name (Child #2)

Birthdate (Child #2) +

Gender (Child #2)

Male

Female

Allergy or Medical Alert (Child #2)

Special Needs (Child #2)

Current Age or Grade this school year? (Child #2)

Child #3

First Name (Child #3)

Last Name (Child #3)

Birthdate (Child #3) +

Gender (Child #3)

Male

Female

Medical Alert (Child #3)

Special Needs (Child #3)

Current Age or Grade this school year? (Child #3)