Adventure Club Registration

Name of Clubber *

Address *

City *

Zip Code *

Grade Entering *

Select One *

Date of Birth *

Emergency Contact

Parent/Guardian Name *

Address *

City *

Zip Code *

Primary Phone *

Secondary Phone *

Email *

Verify Email *

Alternate Contact

Name *

Address *

City *

Zip Code *

Primary Phone *

Secondary Phone *

Health History

Food/Medicinal Allergies:

Current Medications:

Pre-Existing Medical Conditions:

Medical and Liability Release Statement:

I understand that if medical intervention is needed, every attempt will be made to immediately contact the persons listed on this form. If I cannot be reached in an emergency, I hereby give my permission to secure medical treatment for my child as deemed necessary.

I understand the Martensdale Community Church Adventure Club will take all reasonable safety precautions and I understand the possibility of unforeseen hazards and I know the inherent possibility of risk.

I agree not to hold Martensdale Community Church, its Adventure Club leaders or volunteers liable for damages, losses or injuries incurred by the subject of this form.

By placing your name in the E-Signature box below you agree to the terms of this document. The E-Signature Act became law in 2000. Under this law, online “electronic” signatures have the same legal status as a written signature.

Parent/Guardian E-Signature *

Today's Date: *

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If you are registering multiple children, use the back button on your browser after submitting your form. This retains all information in the form and can be used to submit additional registrations.