Name of Child(ren) Attending "Kids4truth Club+" - Include Full name, Birth Date, and Grade they are currently in. Example: (John Doe, 9/1/2016, 3rd Grade) *

Do they attend the After-School program at Lukfata School Public? *

Address

Street Address

City

State

Postal code

Parent/Guardian/Caregivers - FULL NAME *

Parent/Guardian/Caregivers - CELL PHONE NUMBER *

Parent/Guardian/Caregivers - EMAIL *

Additional Parent/Guardian/Caregivers - FULL NAME, CELL PHONE NUMBER, & EMAIL

Other Than Parent Emergency Contact *

Emergency Contact

Details of any known allergies (including any medication):

Details of any other information you feel would be helpful for us to know about your child(ren)

By checking this box, I give permission for my child(ren) to attend the Lukfata Baptist Church. By allowing my child(ren) to attend I give permission for my child(ren)’s information to be stored by Lukfata Baptist Church (this may be on computer) for purposes as considered necessary, and for any photographs and video which may feature my child and be used by Lukfata Baptist Church. (All information will remain confidential)

Should there be any change to the details given on this form I understand that it is my responsibility to inform the church.

In the unlikely event of illness or accident, by checking this box, I give permission for any necessary emergency first aid or medical treatment to be given. In an emergency and if I am not contactable, I am willing for my child(ren) to receive hospital treatment, including an anesthetic. I understand that every reasonable effort will be made to contact me as soon as possible.

LIABILITY RELEASE: In consideration of Lukfata Baptist Church and allowing the above child(ren) to participate in Vacation Bible School activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless Lukfata Baptist Church, its directors, employees volunteers and agents (collectively herein the ""Church") from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above child(ren) while involved in Kid4truth Club.

Furthermore, we (I) [and on behalf of our (my) minor child(ren)] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in activities involved therein.

MEDICAL TREATMENT PERMISSION: We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child(ren) or youth pursuant to this authorization

By checking this box, I consent to receive messages related to KIDS4TRUTH CLUB at Lukfata Baptist Church in Broken Bow, Oklahoma. These messages may include reminders, updates, confirmations, and other important CHURCH-related information. Message frequency may vary. Message and data rates may apply. Reply HELP for help or STOP to opt out.

By checking this box, I consent to receive messages from Lukfata Baptist Church in Broken Bow, Oklahoma, including updates about upcoming events, special services, and church announcements. Message frequency may vary. Message and data rates may apply. Reply HELP for assistance or STOP to unsubscribe.

By checking this box, I understand that my child must be picked up at 7:30 PM and agree to follow all Kids4Truth Club guidelines.

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Parent, Guardian or Caregiver Signature *

Clear

By signing this form, I confirm that all information provided above is accurate and complete to the best of my knowledge. I agree to promptly notify the church of any changes to these details as soon as they occur.