Bible Zone & Mission Possible Registration

If you have any question please e-mail Stephanie at children@hesstonumc.org, or call the church office at

620-327-4305.

Child's First Name

Child's Last Name

Birthday

Grade:

Parents Name(s):

Address:

City:

Zipcode:

Home Phone:

Work or Cell Phone: (whichever is best to get a hold of you during Bible Zone)

Email

I give permission for my child's photo to be taken and name to be used in publication.

Please type if you agree or disagree with the above statement.

Permission Form & Waiver

I/We hereby give permission for the child stated above to attend any Hesston United Methodist Church activity in Hesston Kansas

between September 2010 through August 2011.

I/We release any and all rights or claims for damages against all individuals assisting in instructing and conducting these activities, for any and all injuries,

loss, or damage suffered by them, or in any way connected with those injuries. In the event I/We cannot be reached, IN THE CASE OF AN EMERGENCEY,

I/We hereby give my/our permission to the physician selected by the sponsor to hospitalize, secure proper treatment for, and/or injections, anesthesia or surgery

for the child named above.

Parent or Guardian Name:

By typing your name in the box below, you are providing an electronic signature and are agreeing to the Permission Form & Waiver information above.

Date:

Physician:

Physician Number:

Known Allergens:

Emergency Name & Contact Number:

T-Shirt Size:

Youth Small, Youth Medium, Youth Large,

Adult Small, Adult Medium, Adult Large, Adult XL, Adult XXL

Additional Comments that you would like us to know about:

The suggested donation to cover the cost of meals and supplies is $10.00 per semester. You may make checks payable to HUMC

memo Bible Zone. You may mail the check to HUMC P.O. Box 9 Hesston KS 67062, leave in the basket in the church lobby, or have your child bring it with them to Bible Zone or Mission Possible.

Please submit this form below by hitting the Submit Query button below.