St Mina Class Outing - St Mary Coptic Orthodox Church

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St Mina’s Classes Raising Cane’s Outing:

Date: November, 24th 2024

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Servant's Name *

First

Last

I would like to donate *

Parent's Name

First

Last

Parent's Email

Parent's Phone Number

How many kids are you signing up? (Please select an option) *

First Kid

Name

First

Last

Second Kid

Name

First

Last

Third Kid

Name

First

Last

Fourth Kid

Name

First

Last

Fifth Kid

Name

First

Last

Consent Form

Parent / Guardian Name

Phone

Emergency Contact

Emergency Contact Phone

Insurance Provider

Individual / Group #

Please list any of your child's medications, allergies, or other medical conditions :

For multiple registrations please list the child’s name first then their list for allergies and/or medications.

PARENT/GUARDIAN

SIGNATURE REQUIRED FOR ENROLLMENT

I hereby certify that my child is willing and able to adhere to the event guidelines. If the church chaperones/servants decide that my child must leave early, one of the servants will reaching out to the parent via phone. In the event of an unforeseen incident or accident, I hereby declare that I will not hold liable the church as an organization, or the chaperones in their capacity as church representatives.

In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the church chaperones to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for my child. I also give permission to the medical personnel selected by the church chaperones to order X-rays, routine tests, or treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child.

I grant permission for my child to participate in every activity offered at the event.

Display Current Date

Consent

I agree

Signature

Clear Signature

Donations ($15 per kid) *

Total

Price: $0.00

“Let your light so shine before men, that they may see your good works and glorify your Father in heaven.” Matthew 5:16

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