2017 SuperStart Registration

Student Information

Student's First Name *

Student's Last Name *

Student's Birthdate *

Student's Grade *

Parent/Guardian's Name *

Email Address *

Phone Number *

Address *

Address

City

State/Province

Zip/Postal

Emergency Contact Person *

Emergency Contact Info *

Church You Most Attend *

Food Allergies *

Special Considerations or Restrictions *

Liability Statement

I understand that participation in this event is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release First Christian Church, all employees, volunteers, and related parties from any and all claims or liability arising out of this participation. In case of emergency involving my child, I understand that every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the ability to continue in the program activities.

I Agree to the Liability Release Statement *

Yes

Insurance Information

Insurance Company *

Policy Number *

Event Registration

Superstart Registration

Lasertag

Please fill in a number 1 to pay for your student to play lasertag. This is optional but they will not be able to play if you do not choose this option. Cost is $14.

Total Event Registration & Lasertag Cost

Parent/Guardian Signature *

By placing my name into the above space provided I am agreeing that the information provided is accurate and I give my consent for my child/dependent to attend 2017 SuperStart Event.