Your Name (required)
Your Email (required)
Cell Phone (required)
I would like to serve the following: (check all that apply) popcornsnow conesdrinkswhere needed
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This will be for a half day and no spending the night. The cost is $25 per person including adults that are helping. T-shirts and lunch will be included. Daily Schedule: 8:30-1:30 - Monday thru Wednesday
Name *
Email *
Phone Number *
Address * Street City State Zip Code
Grade Completed * 7th8th9th10th11th12thAdult
Tshirt Size (adult sizes) * SMLXL
Type the code you see in the box below.
Child's Name (required)
Child's Age (required) weeksmonthsyears
Will he/she be eating pizza? YesNo
Parent/Guardian's Name (First & Last)
Parent/Guardian's Email Address
Medical concerns, special needs or food allergies
Emergency Contact (parent/guardian preferred)
Name
Phone
Medical Release
As a parent and/or guardian, I do herewith authorize treatment under the direction of any licensed physician of the minor(s) registered above in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life or cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a resonable effort has been made to reach me.
The undersigned assumes the responsibility for any cost connected with such treatment. I hereby agree to release Southside Baptist Church and its staff and volunteers from liability in the event of injury.
A copy of this authorization can be used as the original.
Medical Insurance Provider
Medical Insurance ID
By checking this box, you verify that this form is completed and submitted of your free will with the sole purpose of authorizing medical treatment under emergency circumstances in your absence.
