EASTWOOD TULSA MOPS 2019-2020 REGISTRATION FORM

Please complete this registration form. Visit our web page at www.eastwoodtulsa.org/mops for information about our group.

Please note: Our MOPS Kids childcare program (subject to availability) is for 6 weeks to 5 years old (entering kindergarten fall 2019).

Questions? E-mail eastwood@eastwoodtulsa.org

First Name and Last Name

This address will receive a confirmation email

Mobile Phone

Address

Birthday

Marital Status

Home Church If no home church, enter NONE.

In the event of an emergency, please provide the name and phone number of your child's father.

Father's Name

Father's Mobile Number

Child Care

If you will need childcare, select YES and complete the CHILD INFORMATION for each child you will bring. Childcare is subject to availability and only for 6 weeks to 5 years old (entering kindergarten in September 2019). If you don't need childcare, select NO and skip to SIGNATURE.

Child care

Child Information

Please only include children who will be participating in the MOPS Kids childcare.
Childcare is subject to availability and only for 6 weeks to 5 years old (entering kindergarten in September 2019).

Child First and Last Name

Gender Male Female

Child Birthdate

Child's Age as of Aug 31, 2018

Allergies/Medical Conditions

#2 Child Information

Complete information for SECOND child or skip to SIGNATURE.

(2) Child First & Last Name

(2) Gender Male Female

(2) Child Birthdate

(2) Child's Age as of Aug 31, 2018

(2) Allergies/Medical Conditions

#3 Child Information

Complete information for THIRD child or skip to SIGNATURE.

(3) Child First & Last Name

(3) Gender Male Female

(3) Child Birthdate

(3) Child's Age as of Aug 31, 2018

(3) Allergies/Medical Conditions

What else would you like us to know about you, your child or your family?

Pick Up Permission

Who has permission to pick up your child(ren) from MOPS Kids?

Name

Relationship

Phone Number

Name (2)

Relationship (2)

Phone (2)

Signature/Consent

By this instrument, I do herby release, acquit, hold harmless and forever discharge EASTWOOD BAPTIST CHURCH, its agents, servants, and employees, and all persons natural or corporate, in privity with them or any of them, from any and all claims or causes of action of any kind whatsoever, including but not limited to actions, suits and/or claims for any bodily injuries, death or property damage which may be sustained by my child while participating in any activity, or activities, including travel to and from such activities and any negligence or lack of care due or claimed to be due to the conduct of any agent, servant, or employee of EASTWOOD BAPTIST CHURCH. By signing this agreement, I give my permission for my child to receive medical attention in the event of any emergency.

I hereby authorize and grant permission for Eastwood Tulsa to use any photos, film, digital imaging, videos, verbal and written statements of the above stated participant or their likeness for promotional, or other uses by Eastwood Tulsa either associated with the project, event, program, or otherwise. I acknowledge that I will not receive compensation for the use of such materials, and I hereby waive any and all claim to any such compensation.

I Agree

Yes No

Signature

Signature Date

Comments/Questions

EASTWOOD TULSA MOPS 2019-2020 REGISTRATION FORM

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