Kids Connection

Parent or Guardian Name *

Email *

Child's Name *

Child's Age *

Child's Grade in School *

Mailing Address *

Home Phone *

Cell Phone *

Emergency Contact Name *

Emergency Contact Phone *

Allergies or Special Needs

Release for Healthcare *

In the event of an emergency or non-emergency situation in which medical treatment is required as a result of participation in the activities of the McPherson First Church of the Brethren, every reasonable effort will be made to contact the persons listed above. If unsuccessful in contacting the persons listed, consent is given for treatment by competent medical personnel. Further, consent is given to youth pastors or volunteers of McPherson First Church of the Brethren to hospitalize, secure proper treatment for, and to administer injection, anesthesia or surgery under recommendation of qualified medical personnel.

Indemnification & Release *

I/we hereby consent to my/our minor attending and participating in youth activities associated with the McPherson First Church of the Brethren, McPherson, Kansas, which may include various modes of transportation such as bus, train, personal automobile, etc. I/We hereby further consent to medical care and treatment being tendered or furnished to said minor in the event such circumstances should arise, and prompt notification of same will be given to the undersigned. I/We, the undersigned, hereby agree to indemnify and hold harmless the McPherson First Church of the Brethren and any individual in his or her capacity as leadership team member, officer, director, trustee, pastor, counselor, advisor or teacher from and against all claims, damages, losses and expenses, including attorney’s fees, arising out of or resulting from participation of said minor in the activities indicated above.

Photography Release *

The McPherson Church of the Brethren has my permission to use my or my child’s photograph publicly to promote the church. I understand the images may be used in print publications, online publications, presentations, websites and social media. I also understand no royalty, fee or compensation shall become payable to me by reason of such use.

Phone