Southside United Methodist Church / Home / Wacky Wednesdays

Register for any/all of our 2018 Wacky Wednesdays by filling out the information below. Please fill out separate forms for each child you are registering. Thank you!

Child's Full Name

Parent(s) Full Name(s)

Email Address

Cell Phone #(s)

Home Phone #(s)

Work Phone #(s)

Street Address

City

State

Zip Code

Does your child have an Allergy (Food, Medicine, Enviornmental, etc)? If YES, please explain:

If applicable, please explain any Additional Information we should know about your child's health:

Since we will be transporting your child for some of these events, we much also ask for their Health Insurance Information (in the event of an emergency):

Health Insurance Company

Health Insurance Policy #

Group Insurance Policy #

Full Name of Insured

In registering my child for these events, I hereby grant my child (above named) permission to attend and participate in all Wacky Wednesday activities of Southside United Methodist Church (hereinafter referred to as SUMC). I agree that the attendance of my child at these events constitutes my agreement with and acceptance to the terms of the Release. I agree that my child's picture or likeness may be included in any photographs or videos taken at the event.

I accept full responsiblity for my child's actions, and I hereby indemnify and hold harmless SUMC, the Mountain Lakes District and the North Alabama Conference of the United Methodist Church, against any and all loss or damage arising from any and all accidents or injuries caused by my child, whether accidentally or willfully, to: (i) property owned by SUMC; (ii) property of those acting as employees, agents or assigns (including, without limitation, volunteers) of SUMC; and (iii) personal injuries or death suffered by any employee, agent, volunteer or staff member of SUMC.

I further accept full responsiblity for my child's safety and I hereby release, hold harmless, and agree to indemnify and defend SUMC, its agents, employees and assigns, including, without limitation, volunteers and staff, from and against any and all damages arising out of, relating to or resulting from my child's participation in Wacky Wednesdays, except to the extent wholly caused by the gross negligence or intentional misconduct of any such volunteer(s) or staff.

In the event of injury or illness of my child while engaged in Wacky Wednesdays, I hereby expressly grant to SUMC, its agents, employees and assigns, permission to seek such medical care (including emergency treatment) as any of such persons reasonably believe is needed, based on their good faith assessment of all attendant facts and circumstances, and I hereby agree to indemnify and hold harmeless SUMC, together with the Mountain Lakes District and North Alabama Conference of the United Methodist Church, from all expenses incurred in obtaining medical treatment for my child.

Electronic Signature (please type your name as you would sign)

Date (MM/DD/YY)

Wacky Wednesdays 2018 Registration