Club 45 Registration

Child's Information:

Name

Birth Date

Grade

School

Address

Allergies/Medical Conditions

Parent or Guardian's Information:

First and Last Name

This address will receive a confirmation email

Cell Phone

Address (if different from above)

Second Parent or Guardian's Information:

First and Last Name

Cell Phone

Address (if different from above)

Additional Information:

Emergency Contact (Other than Parent/Guardian)

Emergency Contact Cell Number

Consent and Certification:

I authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. I also understand that every attempt will be made to notify parents or guardians before procedures proceed. I understand that I will be liable and agree(s) to pay all costs and expenses incurred in connections with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Yes No

I hereby give permission for Powell UMC staff or volunteers to drive my child to and from any events that are offsite from the church. This includes any mission, fellowship, retreat, or any other types of events that may be scheduled.

Yes No

I hereby give permission for Powell UMC, ministers, staff, leadership and/or volunteers to use photos of my child in church publications such as church emails, church website, social media or other church related needs.

Yes No

By typing your name below, you give permission for your child to attend and participate in activities and events sponsored by Powell United Methodist Church to be held on church premises and/or at off-site locations. I understand that I will be notified of specific details for all activities/events. This permission is granted for the 2026-27 program year (9-1-2026 to 8-31-2027).

Date:

Description

2026/2027

Please register your child for participation in Club 45 for the 2026-2027 ministry year.

Club 45 Registration

Description

Please Fix the Following