iRock Children's Registration 25’

Registration Package Info:

Registered children will receive a badge, t-shirt, lunch, and snacks for the week. There will also be a field trip planned during the week.

The price for in-person registration will be $75. We do offer discounted rates for families with more than 2 children. Please email registration@internationalbibleway.org for more information.

Form Disclosure:

By completing this form I agree that IBW and IRock Children's Ministry is released from liability in connection with medical treatment and unavoidable accidents. IRock Children's Ministry also has permission to use necessary medical measures in the event of an emergency. My child has permission to leave the grounds with authorized staff for scheduled trips and outings.

I fully understand the inherent risks involved in the activities my child will be choosing or has chosen. I accept all risks including those activities preliminary and subsequent to the chosen activities. Also, I give IRock Children's Ministry permission to utilize my child's photographs or likeness in promotional materials.

I have read and agree to the fees, conditions, and policies outlined in this form.

Child's Information:

Child's Name

Child's Preferred Name

Child's Gender

Boy Girl

Date Format: xx/xx/xx or xx/xx/xxxx

Child's Birth Date

Child's Grade

Child's T-Shirt Size

X-Small Small Medium Large X-Large

Guardian's Information:

First Name

Last Name

Relationship to Child

Mother Father Guardian/Other

Cell Phone Number

Alternate Phone Number

Personal Email Address

This address will receive a confirmation email

Home Address

Notice: All applications for iRock require at least one emergency contact to be listed in the event that the parent or guardian cannot be contacted.

Emergency Contact No. 1

First Name

Last Name

Relationship to Child

Primary Cell Phone Number

Alternate Cell Phone Number

Emergency Contact No. 2

First Name

Last Name

Relationship to Child

Primary Cell Phone Number

Alternate Cell Phone Number

Medical Information:

Medical Agreement

Parents or guardians must complete the following section for each child participating in the Children's Ministry. Please carefully read and complete the medical section of this form. If you have any questions or concerns regarding this section or form, please email registrar@internationalbibleway.org.

Child's First Name

Child's Middle Name

Child's Last Name

Date Format: xx/xx/xx or xx/xx/xxxx

Child's Birth Date

Child's Age

Please list any significant health conditions the child may have below:

Please list any food or medicine allergies the child may have below:

Note: Any information that does not apply please answer with N/A

Health Insurance Provider

Health Provider's Phone Number

HealthCare Plan Type

Insurance I.D. or Policy Number

Insurance Group Number

Doctor's Full Name

Doctor's Phone Number

Parent/Guardian's Full Name

Parent/Guardian's Phone Number

Authorization Certification & Liability Release Disclosure

By submitting my payment to IROCK Children's Ministry I authorize any medical treatment required if my child becomes ill or involved in an accident.

I give any representative of the International Bible Way Church or the IRock Children's Ministry permission to administer or take my child for authorized treatment. I accept responsibility for any expenses incurred in the medical treatment for my child and assign all coverage to any healthcare provider from my healthcare plans as noted above.

In consideration of the assistance of the church staff in organizing Children's Ministry activities, I release the church, all of its personnel, and any affiliates or assistants who function or accompany children on outings and activities, from all liabilities or claims while my child goes to, attend, or returns from any Children's Ministry activity; I assume all risks involved. This "release" is given on behalf of me, my child, and all family members.

Payment: iRock Registration $65.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

iRock Children's Registration 25’

Description

Please Fix the Following