Form

For more information contact the Children's Minister, Becky Gleason. For fields that do not apply, please type N/A.

Child's First Name *

Child's Last Name *

Date of Birth *

Age *

Grade *

School *

Mother's Name *

Father's Name *

Cell Phone Number *

- Area Code Phone Number

Address *

Parent/Caregiver Email *

I Would Like to Receive KidMin Email Updates *

Yes No I am already on the list!

I Would Like to Receive St. Michael's Mailed Quarterly Newsletter *

Yes No I already receive it!

Emergency Contact Name *

Emergency Contact Phone *

- Area Code Phone Number

Emergency Contact Relationship *

Family Physician *

Family Physician Phone *

- Area Code Phone Number

Baptism Date *

First Holy Communion Date *

Child's Special Needs, Allergies, Notes: *

Permission/Refusal to Publish Media of Student

St. Michael’s by-the-Sea Episcopal Church, its employees or agents, on occasion take photographs, videotape, or digital recordings of the people participating in parish events, to use in any and all media exclusively for the purpose of 1) reporting on the church’s activities through the church printed and electronic newsletters, web site, social media, and press releases; and 2) to promote future activities to be held at or by St. Michael’s by-the-Sea.

Media Release Waiver *

I give permission to St. Michael's by-the-Sea Episcopal Church to publish media of child. I DO NOT give permission to St. Michael's by-the-Sea Episcopal Church to publish child.

Episcopal Diocese of San Diego

Medical Release and Waiver of Liability

I hereby release the Episcopal Diocese of San Diego, and St. Michael’s by-the-Sea Episcopal Church, its directors, officers, employees and volunteers from responsibility and liability for any injury or illness that my child/youth, OR I as an adult participant may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to any x-ray examination, medical, dental or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate), licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I expect to be contacted as soon as possible. The medical information stated above is true and accurate to the best of my knowledge and belief.

Medical Waiver *

Yes I accept this waiver of liability. No, I do NOT accept this waiver of liability.

Signature *

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Type what you see *