KGPC Program Registration

Full Name of Child/Youth: *

First

Last

Date of birth: *

Youth Phone Number:

Youth Email:

Primary Address:

What grade is your child in? *

If between grades, list the grade the child will be in at the start of the next school year.

School Attending in 2023/2024: *

Allergies/Special Needs (Please specify reaction to allergy):

What else do we need to know to best minister to your child?

Parent/Guardian Name 1 *

First

Last

Parent/Guardian Email *

Parent/Guardian Phone *

Does the child live with this parent/guardian? *

Parent/Guardian Name 2

First

Last

Parent/Guardian Email 2

Parent/Guardian Phone 2

Does the child live with this parent/guardian?

Media Policy Our Media Release is as follows: I, the undersigned, on behalf of myself of my child do hereby grant permission to King’s Grant Presbyterian Church (KGPC) and its designees permission to photograph, broadcast, or video my child during KGPC sponsored activities. I hereby grant KGPC permission to use my child’s likeness in photography, videos, motion pictures, sound recording, broadcasts, quotes, testimonies, stories, or any combination thereof, to be released for public viewing and/or hearing, or a combination of the same, through public mass media or through KGPC's publications or presentation throughout the world and forever. I waive any right to review or approve any works created, including written or electronic copy, wherein my child’s likeness appears. I understand and agree that these materials will become the property KGPC. I understand that my child will not be identified by name unless I give my express permission. In addition, I waive any right to royalties or other compensation arising or related to the use of photographs, videos, broadcasts, wherein my child’s likeness appears. I hereby agree to release, defend, and hold harmless KGPC, its directors, officers, trustees, employees, volunteers, agents, contractors, successors, and assigns from any and all claims that I may have now or in the future relating to this Release however arising, including but not limited to, invasions of privacy, right of publicity, trademark infringement, copyright infringement, or defamation. I have read this release before signing below, and I fully understand the contents, meaning, and effect of this Release. *

I understand.

Permission & Agreement

Please read and acknowledge.

I agree and give my permission

I have read and fully understand the contents of the media release form contained above. By checking this box, I grant permission for Kings Grant Presbyterian Church (KGPC) to utilize pictures of my child in the ways listed above.

I agree and give my permission

I have read and fully understand the contents of the media release form contained above. By checking this box, I grant permission for KGPC to only utilize pictures of my child during specific in-house events (ie: posting their photo on bulletin boards, media shouts, and other similar publications).

I agree and give my permission

I have read and fully understand the contents of the media release form contained below. By checking this box I understand that my child’s picture will not be taken at all during KGPC events.

Please sign electronically: *

Date: *

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