Annual Student Registration Form

Yearly form for families with youth and children participating in Kings Circle classes and/or activities. Please fill out one form per household.

Your name *

Email address *

Household Contact Information

Address *

Phone Number *

Secondary Emergency Contact *

Who else could we get a hold of in case of an emergency if you were unavailable? (Please use spouse's name and info if applicable.)

Phone Number

Would you like to receive emails from Kings Circle about upcoming events? *

Yes

Children Info

How many children ages birth - 18 do you have in your household? *

min: 1

Please list the name, gender, birthdate, grade level, and school of each of your children. *

example: Joe Smith, boy, 08/22/2004, 8th grade, linus Pauling middle school

Do any of your children have any medical conditions we should be aware of?

Please list the child's name and their medical condition and/or food allergies.

Emergency Medical Information

In order to best care for your child(ren) in the unfortunate event of an emergency, we encourage every family to consider sharing your health insurance policy number and physician contact information with us. This information may help expedite our assistance in helping your child(ren) get the care they need in the event of an emergency.

Does your child(ren) have medical insurance coverage?

yes

Name of insurance Provider

Name of policy holder

Policy number

Group number

Family Physician's name and contact number

Do you give permission for your Child(ren) to ride on Kings Circle vehicles for events?

I hereby give my permission for all the children listed above to ride the church van. I understand that my child(ren) will be under adult supervision at all times. I have received a copy of the van safety rules and my child(ren) will abide by them. I further agree to direct my child(ren) to conform to the fullest with directions and instructions of the adults in charge. I further understand that in signing below, I release and hold harmless Kings Circle, its trustees, officers, district and national organization, employees, owners, drivers, and any volunteers from any liability, past, or future, fully and completely.

Please Type Yes or No *

Does your child(ren) need a ride for Wednesday Night Community Groups?

If so, please give a pick up address if it is different from your home address given above.

Medical Release and Consent

Child(ren) may not keep any medications with him/her. Please give any medications to the event/ministry coordinator. Medications must be in original prescription container.

Medical Liability & Release: I understand that Kings Circle provides liability insurance coverage for church sponsored activities. This insurance is secondary to my own insurance coverage, which is agreed as being primary. In the event of injury to a non-insured participant and in the event of a claim against the insurance carrier for the church, I agree to assume full financial responsibility for all such related costs. I understand that, in the event that medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give my permission to the staff or sponsor to secure the services of a licensed physician to provide the care necessary, including anesthesia, for my child's well being. It is understood I can expect communication from church representatives as immediately as is possible in such emergency situations. I understand all reasonable safety precautions will be taken at all times by Kings Circle and its agents during this activity. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Kings Circle, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by my child. This form gives my permission for my child(ren) listed above to participate in all activities of Kings Circle and to be transported by church van or private car when necessary. I understand that all events will have adult supervision. In consideration of the benefits to be derived from these activities, i hereby voluntarily waive any claim against Kings Circle, the sponsors, and the owner/driver of the car or van furnishing transportation to any event. i further agree to direct my son/daughter to conform to the fullest with the directions and instructions of the sponsors in charge. I also agree that my consent will remain in effect for as long as my child(ren) are involved in Kings Circle's ministries and activities, or until my child turns eighteen years old.

Please Type your full legal name to sign. *

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