Five Oaks Neighborhood Kids Club Parent Registration

"*" indicates required fields

Parent/Guardian*

Email*

Address*

Zip Code*

Phone*

Alternate Phone

Family Doctor*

Emergency Contact*

Names of those you give permission to pick up your child(ren) after a Lighthouse event*

First Name

Last Name

Other Health Concerns?

Number of Children who attend Lighthouse*

Child 1

1. Child's Name*

First Last

Age*

Please enter a number from 1 to 99.

Gender*

Date of Birth*

T-shirt Size*

School*

Grade*

Allergies

Child 2

2. Child's Name*

First Last

Age*

Please enter a number from 1 to 99.

Gender*

Date of Birth*

T-shirt Size*

School*

Grade*

Allergies

Child 3

3. Child's Name*

First Last

Age*

Please enter a number from 1 to 99.

Gender*

Date of Birth*

T-shirt Size*

School*

Grade*

Allergies

Child 4

4. Child's Name*

First Last

Age*

Please enter a number from 1 to 99.

Gender*

Date of Birth*

T-shirt Size*

School*

Grade*

Allergies

Child 5

5. Child's Name*

First Last

Age*

Please enter a number from 1 to 99.

Gender*

Date of Birth*

T-shirt Size*

School*

Grade*

Allergies

HOLD HARMLESS RELEASE

I give my permission for my child(ren) to attend Five Oaks Kids Club/Lighthouse Community Outreach (LCO) activities both at the Five Oaks park and on the covered front porch of 5202 Margo St. and 5018 Sitca in the neighborhood. I also give my permission for the Lighthouse volunteers to bring my children to and from the park for drop off and pick up. I hereby release LCO along with its directors, officers, administrators, or other agents from all liability or damages for any and all injuries arising while my child participates in LCO activities. In case of emergency, every effort will be made to contact the parents or guardians on record. In the event nobody on record can be contacted, I hereby give my permission to the physician selected by the sponsor to hospitalize and secure proper treatment (including surgery and anesthesia) for my child, and I do hereby agree to indemnify and save harmless any LCO representative from any claim by any person whomsoever on account of care and treatment of said participant.

Signature of Parent*

PHOTOGRAPH/VIDEO RELEASE

I grant Five Oaks Ministry/Lighthouse Community Outreach (LCO) and those acting with its authority, permission to use any photograph/video of my child(ren) or me for LCO publications, websites, electronic and digital media, publicity, advertising, or other purposes related to promoting LCO. All photographs/videos will remain the property of LCO. LCO will not sell any photographs/videos nor will said photographs/videos be used for purposes not stated herein. I understand that there will not be any payment or remuneration given for the right to this permission.

Signature of Parent*

DISMISSAL RELEASE

I understand that when my child attends Five Oaks/Lighthouse Community Outreach’s (LCO) Neighborhood Kids Club or other activities, they will stay for the duration of activities. I understand that LCO strongly recommends I pick up my children for their safety, but if my child(ren) have permission to walk or ride their bike home, I hereby release LCO as well as its directors, officers, administrators, or other agents from all liability or damages for any and all injuries arising while my child travels home.

Signature of Parent*

Date*