VBS 2022 Registration

Child Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Child Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Name *

First Name

Last Name

Parent Phone *

(###)

###

####

Parent Name 2

First Name

Last Name

Parent Phone 2

(###)

###

####

PERMISSION, MEDICAL & MEDIA RELEASE *

By checking "yes" below and completing this form I hereby give permission for my child, to participate in the events and activities of The Christian and Missionary Alliance of Sidney, NY (referred to as Gateway Alliance Church from here on). I hereby release and indemnify Gateway Alliance Church, its staff, and volunteers from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in these events. By checking "yes" below and completing this form I grant permission for the administration of first aid to my child by Gateway Alliance staff and volunteers, as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand that I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In case of a medical emergency, I understand that every effort will be made to contact the parents / guardian of the participant(s). In the event I cannot be reached, I hereby give permission to the physician selected by the adult staff or volunteers to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery, if deemed as necessary for my child. By checking "yes" below and completing this form I hereby give permission to Gateway Alliance Church of Sidney, NY to use my child's photo, image or likeness in all forms of media for website, print, social media, advertising, portfolio, stock photography, editorial and/or PowerPoint presentations altering without restrictions, and all other lawful purposes. I understand my child and I are entitled to no compensation. I release the photographer from all forms of claims and liability related to my child's photo/image/likeness usage.

Yes