Truth Tabernacle

KIDZ POWERED BY JESUS 2023-2024

KPBJ CLUB REGISTRATION

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PLEASE COMPLETE ONE FORM FOR EACH CHILD.

Intended for children *TK-6th Grade as of September 1. *TK = One year prior to starting Kindergarten

Child's Name *


First Name	Last Name

Grade (as of September 1) *

Date of Birth (Please include year) *

Age *

Gender *

Select from list

T-Shirt Size *

Select from list

Father or Guardian *


First Name	Last Name

Best number to reach Father or Guardian *

Phone Number

Mother or Guardian


First Name	Last Name

Best number to reach Mother or Guardian *

Phone Number

Physical Address *


Address

Address Line 2

City	State	Zip Code

Mailing address (if different)


Address

Address Line 2

City	State	Zip Code

Primary E-mail address for communication

Email Address

Is your child allergic to peanut butter? *

Select from list

Please note anything we should know about your child. i.e. special needs; other allergies or in general.

AUTHORIZATIONS

I hereby attest that I am (we are) the legal parent/guardian(s) of the above-named child and hereby consent to the child's participation in the activities described. I understand that activities of the kind described may result in physical injury to my child. Knowing this, I grant permission for my child to participate in those activities.

I give my child permission to: *

Select all that apply

If my child is ill I will not allow them to participate. *

Select one

I agree

Permission to Participate in KIDZ POWERED BY JESUS (KPBJ) Club *

Select one

Yes
No

Additional person (18+) authorized to sign your child out of Club (If applicable)


First Name	Last Name

Phone

Phone Number

Additional person authorized to sign your child out of Club (If applicable)


First Name	Last Name

Phone

Phone Number

I give my permission for my child's photo to be uploaded to media platforms administered by KPBJ and Truth Tabernacle *

Select one

Yes
No

LIABILITY RELEASE | MEDICAL INFORMATION | IN CASE OF EMERGENCY INFORMATION |

As a parent and/or guardian, I do herewith authorize treatment under the direction of any licensed physician of the following minor in the event of a medical emergency which in the opinion of the attending physician may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me by phone at the number listed below. The undersigned assumes the responsibility for any costs connected with such treatment and I (we) hereby releases Truth Tabernacle staff, leaders, or directors of the Kidz PBJ Club from any liability. This release form is completed and signed of my own free will for the purpose of authorizing medical treatment under emergency conditions in my absence. This release form is in effect for any and all Kidz PBJ activities from this day forward. As the undersigned, I also waive any claims against Truth Tabernacle and its volunteers for damage or injury to the person or property of my child while involved in all activities, both on or off the church premises.

Do you agree with the Statement of Liability? *

Select one

I agree


First Name	Last Name

Phone number to reach you on WEDNESDAY nights *

Phone Number

Family Physician


First Name	Last Name

Physician's Number

Phone Number

Insurance Carrier

Specific medical concerns (i.e. allergies, chronic illnesses, other conditions)

Medications

Additional contact in case of emergency


First Name	Last Name

Phone Number

* required