GEMS, Cadets, Kingdom Kids Registration (2023-24) How many children are you registering?1234More than 4Child #1 InformationChild's Name(Required) First Last Which program are you registering this child for?(Required) Kingdom Kids GEMS (girls, 1-8 grade) Cadets (boys, 1-7 grade) Birthdate(Required) Month Day Year Grade(Required)Pre-KKindergarten1st grade2nd grade3rd grade4th grade5th grade6th grade7th grade8th gradeGenderMaleFemaleShirt Size(Required)youth smallyouth mediumyouth largesmallmediumlargex-largeChild #2 InformationChild's Name(Required) First Last Which program are you registering this child for?(Required) Kingdom Kids GEMS (girls, 1-7 grade) Cadets (boys, 1-7 grade) Birthdate(Required) Month Day Year Grade(Required)Pre-KKindergarten1st grade2nd grade3rd grade4th grade5th grade6th grade7th gradeGenderMaleFemaleShirt Size(Required)youth smallyouth mediumyouth largesmallmediumlargex-largeChild #3 InformationChild's Name(Required) First Last Which program are you registering this child for?(Required) Kingdom Kids GEMS (girls, 1-7 grade) Cadets (boys, 1-7 grade) Birthdate(Required) Month Day Year Grade(Required)Pre-KKindergarten1st grade2nd grade3rd grade4th grade5th grade6th grade7th gradeGenderMaleFemaleShirt Size(Required)youth smallyouth mediumyouth largesmallmediumlargex-largeChild #4 InformationChild's Name(Required) First Last Which program are you registering this child for?(Required) Kingdom Kids GEMS (girls, 1-7 grade) Cadets (boys, 1-7 grade) Birthdate(Required) Month Day Year Grade(Required)Pre-KKindergarten1st grade2nd grade3rd grade4th grade5th grade6th grade7th gradeGenderMaleFemaleShirt Size(Required)youth smallyouth mediumyouth largesmallmediumlargex-largeI have more children to register.If you are registering more than 4 children, you will need to fill out the form a second time to include your other kids.General InformationAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Church Parent/Guardian InformationParent/Guardian name(Required) First Last Phone(Required)Contact Email(Required) Is Parent/Guardian Address same as above?(Required) Same address Different address Parent/Guardian Address (if different from above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Emergency Contact(Required)Name of a trusted relative, friend, or neighbor we may call if parent/guardian is unavailable First Last Secondary Emergency Contact (Phone)(Required)Medical and Release InformationDoes this child have any allergies, medical conditions, or cognitive concerns that we need to be aware of?(Required) Yes No Medical NotePlease list the allergies, medical conditions, cognitive concerns. All responses are confidential.Family Doctor Family Doctor PhoneHealth Insurance Provider Health Insurance Policy Number Medical Release(Required) I authorize Seymour Church to seek medical care for required servicesMedical Release: By typing my name below and submitting this digital form, I, as the parent/guardian of the aforementioned child, authorize the treatment by a qualified and licensed medical doctor of my child in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if treatment is delayed. This authority is granted only after a reasonable effort has been made to reach me. I acknowledge that typing my name below constitutes my digital signature and agreement to this Medical Release. Release of Liability(Required) I consent to the liability release belowI hereby approve of my child’s participation in the Cadets, GEMS, or Kingdom Kids children’s programs at Seymour Church. I understand that there are risks associated with all activities, including children’s programs. I agree not to hold Seymour Church, staff, leadership, or volunteers liable for any harm that may accidentally occur through the normal course of their programs. I understand that everyone will make every reasonable attempt to provide a safe and caring environment for my child. I acknowledge that typing my name below constitutes my digital signature and agreement to this Release of Liability.Field Trip Authorization(Required) I authorize my child to go on field trips with Seymour Church.I release any individuals from liability in case of accident during related activities, as long as normal safety procedures have taken place. I understand I will be notified before each event and I will notify the leader if I do not wish for my child to participate.Media Release I give Seymour Church permission to use my child’s photo/video/interview in media, website, or publications.Usually these pictures and videos will be used as a way of sharing with the broader church community what is happening in our children’s ministry programs.Digital Signature(Required)By typing your name below, you acknowledge that this constitutes your digital signature and agreement for the authorizations and releases of this form. Date(Required) Month Day Year