Registration Form - 1 per child

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* 1. Child's Name:

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* 2. Child's gender

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* 3. Child's Age:

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* 4. My child is potty trained

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* 5. Date of Birth in MM/DD/YYYY format

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* 7. Last school grade completed:

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* 8. Name of Parent(s)/Guardian

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* 9. Street Address:

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* 10. City, State, and Zip Code:

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* 11. Parent/Caregiver's Cell Phone:

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* 12. Email Address:

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* 13. Home Church:

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* 14. Allergies or other medical conditions:

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* 15. In case of emergency, contact: (put name, relation, and contact info)

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* 16. Medical Care Release: In addition I give my permission for proper medical care to be given to my son / daughter by the proper medical authorities in any case as is deemed necessary.

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* 17. Liability: In consideration of the acceptance of the right to participate, entrants, participants, and spectators by execution of this form, release & discharge Crosby Church, the officers and members of Crosby Church and/or anyone else connected with management or presentation from any & all known and unknown damages, injuries, looses, judgments and/or claims from any causes whatsoever that may be suffered by any entrant to his/her person or property; further each entrant agrees to indemnify all the foregoing entries, firms, persons and bodies from any and all liability occasioned from the conduct of entrants or any participant assisting or cooperating with entrant and under direction or control of entrant.

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* 18. I affirm that all of the above is accurate to the best of my knowledge. I will contact the church office at 281-328-1310 if I have questions or concerns.

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* 19. Signature of Parent / Guardian

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