Converge Kids Registration

Please complete this to register your child for Converge Kids during our service. This is currently offered from birth through third grade.

Your name *

Email address *

Today's Date: *

Phone number *

Address *

Is anyone besides the Parent/Guardian listed above allowed to pick up your child? *

Emergency Contact name, relationship to child, and phone number *

How many children do you have? *

Child #1

Please fill out information below for child #1

Name *

Date of Birth *

Grade

Allergies *

Additional information about Child #1 our staff will need to know? *

Waiver of Liability and Medical Release

We understand the arrangement and believe that the necessary precautions and plans for the care and supervision of my child(ren) will be taken during their participation in Converge Kids programs. Beyond this, we will not hold Converge Community or the person supervising the program responsible. In case of emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give the Converge’s leadership, staff, or other emergency medical personnel permission to act on my behalf in seeking emergency medical treatment for my child in the event that such treatment is deemed necessary by the volunteer, leadership, or church staff. I give permission to those administering emergency medical treatment to do so using measures deemed necessary. I absolve Converge Community, and/or church personnel from Liability in acting on my behalf in this regard so long as they are not grossly negligent. I, as a parent or guardian of (a) child(ren) participating in Converge Kids programs at Converge Community, accept the responsibility for all expenses arising from medical care for injuries to my child(ren) while participating in these activities.

Your child(ren) may be photographed or filmed while participating at Converge Community. Their photo may be used for promoting or sharing activities from Converge Kids or church related events, in printed materials and/or electronically on the internet.

I acknowledge and agree to the above statement *

COVID-19 Acknowledgement & Assumption of Risk & Self-Monitoring

COVID-19 is contagious and is spread mainly from person-to-person contact, Converge Community has put in place preventative measures to reduce the spread of COVID-19. However, I acknowledge that, Converge Community cannot guarantee that its participants, volunteers, or others in attendance will not become infected with COVID-19. I knowingly and freely assume any risk related to illness and infectious diseases, such as COVID-19, even if rising from the negligence or fault of the Released Parties.

I also agree to self-monitor my child(ren) for signs and symptoms of COVID-19 (symptoms typically include: fever, cough, and shortness of breath) and agree to keep them at home instead of participating in person, if my child or someone in my family, is displaying these symptoms.

I acknowledge and agree to the above statement *

All of the information presented above is true and complete to the best of my knowledge, and my typed signature below will be considered legally binding. *