2024-2025 GBPC Kidz Aftercare K-5 Program

Child's Name

Birth date

Parent/Guardian

Address

This address will receive a confirmation email

Phone

Grade

Medical/Health Insurance Information

Medical Doctor & Phone Number

Insurance Company

Policy Number/Group Number

Any Allergies/Medications/Medical Issues

Emergency Contact Name & Phone Number

Alternate Pick-up person/Phone Number

Transportation

If your child attends Gulf Breeze Elementary: A SR County school bus will drop your child at our location. If your child attends Oriole Beach Elementary, our church van will pick up on TUESDAY ONLY. PLEASE respond what transportation your child be be using, BUS, VAN or DROP OFF by Parent.

Days your child will attend:

Monday Tuesday (NAVS KIDZ CLUB!) Wednesday Thursday Friday

Elementary School your child attends:

Gulf Breeze Elementary Oriole Beach Elementary Other

Permission for Publicity

On occasion, Gulf Breeze Presbyterian Church takes photographs or makes an audio or videotape recording of children and/or adults involved in church/youth activities. I consent to the use of any such audio or visual records of the child names above or me, if I am participating to be used, distributed or displayed as agents of the church see fit.

Permission for Publicity

I give permission I DO NOT give permission

Permission/Waiver Release of Liability

Child's Name

By signing this waiver form, I grant permission for the child named above or I, if I am a participant, to participate in and engage in the Aftercare Kids Program and/or Navigators KIDZ Club of Gulf Breeze Presbyterian Church. My child or I are physically and mentally able to participate in these activities unless I have already discussed it with one of the leaders. I acknowledge that there are certain risks involved in said activities and have discussed them with my child if necessary. I release Gulf Breeze Presbyterian Church, its affiliates, volunteers, and employees of all responsibilities for any injuries, to body or property, which may occur to my child during these activities, except for negligence. In the event of an emergency, in which I or the alternate contact cannot be reached, I authorize the adult leaders to make medical decisions for my child, and to administer first aid, if deemed necessary. I further agree to indemnify and hold harmless Gulf Breeze Presbyterian Church and its affiliates, volunteers, and employees of any and all claims arising from my child’s or my participation in activities or as a result of injury or illness of my child or me during such activities, including but not limited to exercising any medical decisions or administering any first aid in the circumstances referred to above, except for negligence. I represent that I am the participant, or parent/guardian of child listed above, who is under 18 years of age. I have read the Permission/Waiver Form and am fully in agreement with the contents thereof. I give permission for the child named above or I to fully participate in the activities of Gulf Breeze Presbyterian Church. Please respond with a Yes, I agree or a No, I disagree.

Signature of Participant or Parent/Guardian

Date:

2024-2025 GBPC Kidz Aftercare K-5 Program - BEGINS August 12th

Description

2024-2025 GBPC Kidz Aftercare K-5 Program - BEGINS August 12th

Description

Please Fix the Following