Please print out and mail/or bring in to Ms. Caroline.
To mail send to:  Mt. Sinai Congregational, UCC, 233 North Country Road, Mt. Sinai NY 11766

 

2011/2012 Sunday School

Registration & Medical Waiver Form

 

Please fill out all information requested below (one registration form per child) and return to the church. *

 

Participant Information:

Name: ____________________________________________________________

 

Age/Grade: _____________________ Date of Birth: ______________________

 

Concerns: (allergies, etc.)_____________________________________________

 

Who is authorized to pick up your child? _________________________________

 

Parent/Guardian Names:_____________________________________________

 

Address:___________________________________________________________

 

Phone: ___________________________ Email: ___________________________

 

*To continue to help ensure the safety of our youth, we required background checks on all of our volunteers that work with the children. We ask each family to please pay a $10.00 fee to help defray the costs of the background checks. If you have difficulty paying this, please contact Rev. Diane so that she may assist you further.

 

 

 

Medical Release: In the event of an emergency, I authorize the administration of any first aid, transport, examination, diagnosis, and/or treatment that is deemed necessary by Mt. Sinai Congregational Church or by any paramedic, doctor,  nurse, physician or dentist.

 

Parent/Guardian Signature _______________________________ Date _____________

(REQUIRED if participant is under 18 OR covered by parent’s insurance)

 

DISCLOSURE AND ACKNOWLEDGEMENT OF RISK

 

The undersigned covenants that he or she will not sue Mt. Sinai Congregational Church or otherwise pursue any claims for any risks or injuries indentified in this document or otherwise arising out of the programs. The undersigned agrees to indemnify Mt. Sinai Congregational Church, provide a defense, against any and all claims for any risks or injury arising out of, or in connection with, the programs.

 

Parent/Guardian Signature _______________________________ Date _____________

(REQUIRED if participant is under 18)