REGISTRATION FORM Your Name (Parent/Guardian) * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Your Phone * (###) ### #### Email Address * Date/Chamber Event you are registering your KIDZ for? * October 11, 2016 (B3) October 18, 2016 (Lunch & Learn) November 2016 (B3) December 2016 (B3) January 2017 (B3) February 2017 (B3) March 2017 (B3) April 2017 (B3) May 2017 (B3) June 2017 (B3) Emergency Contact * In the event that we cannot find you at our Chamber event and help is needed. Who should our volunteers contact about your children? First Name Last Name Emergency Contact Phone # (###) ### #### In the event that an injury or accident occurs and we are unable to find or reach you or your emergency contact, which hospital should your child be taken to? * Do any of your children attending ChamberKIDZ have any diagnoses, diseases, or allergies that we should be aware of? Please describe briefly so we can keep your child(ren) as safe and healthy as possible while they are in our care. This information will only be shared with the volunteer supervisor and sitters watching your kids. This includes food allergies, drug allergies, other known irritants. No, none of my children have any physical health or mental health illnesses or challenges. Yes, Child #1 Yes, Child #2 Yes, Child #3 Yes, Child #4 Yes, Child #5 Yes, Child #6 Any special instructions or information our volunteers should have about your child(ren)? * Hold Harmless Agreement By checking the box below you agree to hold harmless any persons or institutions associated with the Somerset Chamber of Commerce, the Somerset School District, and all other parties involved with ChamberKIDZ of any liability, wrong-doing, accident or injury, or any and all other negative situations. You agree to voluntarily leave your child(ren) in the care of volunteers during the dates and times that ChamberKIDZ child care is offered. If you do not agree to these and/or any and all other release of indemnity clauses then please do not continue with this form. Yes, I agree. Name (Child #1) * First Name Last Name Date of Birth (Child #1) * MM DD YYYY Name (Child #2) First Name Last Name Date of Birth (Child #2) MM DD YYYY Name (Child #3) First Name Last Name Date of Birth (Child #3) MM DD YYYY Name (Child #4) First Name Last Name Date of Birth (Child #4) MM DD YYYY Name (Child #5) First Name Last Name Date of Birth (Child #5) MM DD YYYY Name (Child #6) First Name Last Name Date of Birth (Child #6) MM DD YYYY Thank you!
