MEGA Fun Day Registration Form

Date: January 19th

Time:
Drop Off: 8:30 am - 9:00 am
Pick Up: 5:00pm - 5:30pm

Location: Centerville Community Church
401 Wilson Drive Centerville, GA

Breakfast and Lunch will be provided for all participants

Guardian's Name

Guardian's Email

This address will receive a confirmation email

Guardian's Phone Number

Guardian's Address

Participant's Name

Participant's Address (If Different)

Participant's Gender

Participant's DOB

Emergency Contact's Name

Emergency Contact's Number

Emergency Contact's Relationship to child

Does your child have any allergies? If yes, Please specify:

Does your child have any medical conditions we should be aware of? If yes, Please specify:

Are there any special instructions or concerns we should know about your child? (e.g., dietary restrictions , behavioral issues, etc.)

I hereby give consent for my child, named above, to participate in MEGA Fun Day hosted by Centerville Community Church. I understand that reasonable precautions will be taken to ensure the safety and well- being of my child during the event. I, also, understand by allowing my child to participate in MEGA Fun Day there is a risk of injury. I hereby release, discharge, and hold harmless, Centerville Community Church, its employees, volunteers and other representatives from any claims arising out of or relating to any physical injury that may result to the registering player while participating in MEGA Fun Day. In the event of an emergency, l authorize the staff/volunteers to seek medical treatment for my child if necessary. I also understand that I will be promptly notified in case of any emergency. (Signature Required)

Payment $10.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

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MEGA Fun Day Registration Form

Description

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