Poland Presbyterian Church
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Registration & Releases
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Form Completed By
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First
Last
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Relationship to child(ren)
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Date completed
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Number of children registering:
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Home Address:
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Phone Number
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Email
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Check all programs your child(ren) will attend this year:
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Sunday School
Wonderful Wednesdays
Middlers
Confirmation
Senior High Youth Group
Teen Summer Community Mission Work
List below for each child you are registering; Child's 1st & last name, birthdate and grade entering .
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Emergency Contacts:
Emergency Contact #1 Name
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Relationship to Child of #1 Contact:
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Contact #1 Phone
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Emergency Contact #2 Name
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Relationship to Child of #2 Contact:
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Contact #2 Phone
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Privacy Information:
All the information recorded on this form is collected and managed in accordance with the PPC Church Privacy Policy. This information has been collected for the primary purpose of PPC and may be used for any children's activities conducted or promoted by PPC.
Please list name of anyone else who you authorize to pick up your child/ren in your absence, while in the care of PPC
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Phone Number
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Please list any family situations we should be aware of:
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Please list ANY allergies or health concerns your child(ren) has below.
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Permission to Participate in Program Activities:
I consent to my child(ren) taking part in the approved program of activities.
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Yes
No
I give my permission for my child(ren) to be photographed or videotaped. I understand that these images may be displayed in PPC's church publications, church buildings or website. I understand as a precaution my child's name will not be published or linked with photographs.
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Yes
No
I authorize the leader/s in charge of the above mentioned group where it is impractical to communicate with me, to arrange for my child(ren) to receive such medical treatment as the leader/s may deem necessary at any time during the activities of PPC. I appreciate that every care will be taken by the leaders and those connected with the group cannot be held responsible for personal injury, loss or theft of property affecting my child(ren).
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CORONAVIRUS (COVID-19) ACKNOWLEDGMENT AND WAIVER:
Thank you for allowing your child to participate in our programs at the Poland Presbyterian Church (hereinafter referred to as the “PPC”). This acknowledgment and waiver was put together by the PPC to inform you of our commitment to maintaining the health and safety of all participants, as well as to obtain your acknowledgment of required public health and safety measures, and a waiver against holding us and related parties responsible for COVID-19 exposure or to any other communicable disease you, your child or related parties may incur during or after your child’s attendance and participation in the above referenced program at PPC.
You acknowledge that the PPC has taken all appropriate steps to implement protocols issued by public health authorities for slowing the transmission of COVID-19. You represent that you, your child or any other person with which you or your child have come in contact with, has not tested positive for COVID-19 in the last 14 days, or has recently been exposed to any person who tested positive for COVID-19, and has no symptoms associated with COVID-19. In addition, you agree to immediately advise the PPC if, within 14 days you, your child or anyone in close proximity to your child are diagnosed with COVID-19; or exhibit any symptoms associated with COVID-19. You and your child agree to take all appropriate actions to adhere to personal hygiene and social distancing guidelines as prescribed by public health authorities.
In consideration of the PPC permitting your child to participate in the above described activity or program at PPC, you covenant not to sue, PPC, its teachers, staff, volunteers, directors, officers, employees and their representatives and agents. Further, you release, waive, and discharge the PPC from any and all liability to you and/or your child, or others you may come in contact with, for any loss or damage, and any claim or demands on account of an injury to, or an illness or death of, you, your child or any third-party related to COVID-19, whether caused by the claimed negligence of PPC, whether known or unknown, suspected or unsuspected, which now exists or did exist or otherwise while or after your child attended the above referenced program at PPC. You further agree to indemnify and save and hold PPC harmless, for any loss, liability, damages or costs they may occur, whether caused by the claimed negligence, whether active or passive, or otherwise of you or your child.
You further agree that this Agreement is intended to be as broad and inclusive as possible and that if any portion is held invalid, it is agreed that the balance shall continue in legal force and effect.
You have read, understand and agree to the terms of this agreement
and agree to voluntarily sign this agreement. You are aware that you may be giving up valuable legal rights for you, your child and all others living in your home, including the right to seek to recover damages from PPC, in case illness, injury or death from exposure to COVID-19, and any other communicable disease.
I have read and agree to terms of Covid-19 Waiver?
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Yes
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