Name of Guardian *

First Name

Last Name

Cell Phone *

Number to be contacted in case of an emergency

(###)

###

####

Are any of your keiki deaf or hard of hearing?

Please check if your child will be part of the deaf/hoh group

Yes

No

By registering my keiki for Keiki Day at University Avenue Baptist Church (UABC), I give my consent for UABC to use my child's photographs and video footage in church promotion, publicity, and website. (Please check below) *

If you choose to not permit us to take photos of your child at this event, please be sure your child receives an armband at registration on June 28.

I Do

I Do Not

By registering my keiki for Keiki Day at UABC, I, on behalf of myself and/or the minors I have registered, do hereby release, forever discharge and agree to hold harmless UABC, its pastor staff, leadership, employees, and volunteers from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by myself or those I have registered while participating in Keiki Day at UABC. I and the minor(s) I am registering assume all risk of personal injury, sickness, death, damage and expense as a result of participation Keiki Day at UABC.

I Do

I understand that every effort will be made to contact me in case of emergency. If UABC is unable to reach me, I give my authorization and permission to the UABC the Keiki Day team to obtain necessary medical attention in case of sickness or injury to my child.

I Do