Mom2Mom Registration | Moody Church

Registration

Your Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
What is your home church?
Publicity/Consent Waiver*
- I have read the consent waiver
Publicity ConsentI allow my picture and/or my child's picture to be used by the Mom2Mom Family Ministry for various needs such as, but not limited to, newsletters and/or The Moody Church website.Consent and ReleaseI am the parent/legal guardian of any children included in this registration and have the authority to consent to their participation in The Moody Church Mom2Mom’s Ministry. I consent to their participation in the functions, programs, and activities of that Ministry during the 2017/2018 program year (September through April), including any and all programs and activities customarily associated with a church children’s group.I agree that The Moody Church, its Board members, employees, agents, and volunteers shall not be liable for damages, losses, diseases, injuries, or death while attending or participating in a program, function, or activity of The Moody Church Mom2Mom’s Ministries or while traveling to and from any such program, function, or activity. I hereby release and waive any claims which I or my child(ren) may have or hereafter acquire against The Moody Church, its Board members, employees, agents, or volunteers for any such damages, losses, diseases, injuries, or death.
Add Registrant #2*
Child's Name*
First Last
Birth Month*
Birth Day*
Birth Year*
Are both parents living at home?*
If no, who has legal custody of the child?
If the person who regularly brings the child to Mom2Mom is other than above, please provide her name.
What school does your child attend?
Emergency contact person*
Emergency contact phone number*
Emergency contact relationship to child*
Family doctor
Family doctor phone number
Does your child have medical concerns of which the church should be aware (allergies, etc)?*
If yes, please describe.
My child will attend:*
My child is physically fit and adequately trained to participate in programs and events except (please specify all exceptions):
Add Registrant #3*
Child's Name*
First Last
Birth Month*
Birth Day*
Birth Year*
Are both parents living at home?*
If no, who has legal custody of the child?
If the person who regularly brings the child to Mom2Mom is other than above, please provide her name.
What school does your child attend?
Emergency contact person*
Emergency contact phone number*
Emergency contact relationship to child*
Family doctor
Family doctor phone number
Does your child have medical concerns of which the church should be aware (allergies, etc)?*
If yes, please describe.
My child will attend:*
My child is physically fit and adequately trained to participate in programs and events except (please specify all exceptions):
Add Registrant #4*
Child's Name*
First Last
Birth Month*
Birth Day*
Birth Year*
Are both parents living at home?*
If no, who has legal custody of the child?
If the person who regularly brings the child to Mom2Mom is other than above, please provide her name.
What school does your child attend?
Emergency contact person*
Emergency contact phone number*
Emergency contact relationship to child*
Family doctor
Family doctor phone number
Does your child have medical concerns of which the church should be aware (allergies, etc)?*
If yes, please describe.
My child will attend:*
My child is physically fit and adequately trained to participate in programs and events except (please specify all exceptions):