Name: GPConnect 2024-25
Start: 2024-08-23T18:00:00-05:00
End: 2024-08-23T21:00:00-05:00
Location: Activity Center

Participant Information:

First Participant Name

First Last

First Participant's Date of Birth*

First Participant's Age

Current Grade (If Applicable)

Medical/Special Needs for First Child (Alergies, Medications, etc.)

Do you need to add more children to your registration?

Yes
No

Additional Participants

Is a Second Participant Attending?*

Yes
No

Second Participant Name

First Last

Second Participant's Date of Birth*

Second Participant's Age*

Current Grade (If Applicable)

Medical/Special Needs for Second Participant (Alergies, Medications, etc.)

Is a Third Participant Attending?*

Yes
No

Third Participant Name

First Last

Third Participant's Date of Birth*

Third Participant's Age*

Current Grade (If Applicable)

Medical/Special Needs for Third Participant (Alergies, Medications, etc.)

Is a Fourth Participant Attending?*

Yes
No

Fourth Participant Name

First Last

Fourth Participant's Date of Birth*

Fourth Participant's Age*

Current Grade (If Applicable)

Medical/Special Needs for Third Participant (Alergies, Medications, etc.)

Parent/Guardian's Information:

Parent/Guardian's Name*

First Last

Address*

Street Address City State ZIP Code

Phone Number:*

Email Address:*

Emergency Contact Name:*

First Last

Emergency Contact Phone Number*

Relation to child/children*

Additional Adults That Can Pick Up (Optional)

Is there anyone who is not allowed to pick up your child?*

Yes
No

If you clicked, yes please indicate the name so that we can ensure your child’s safety.

Liability Waiver

In recognition of the possible danger connected with any physical activity of the participant, I hereby knowingly and voluntarily waive any right or cause of action of any kind whatsoever arising as the result of such activity for which any liability may or could accrue to Germantown Presbyterian Church – GPConnect, sponsors, agents, employees, volunteers, or instructors.

Untitled*

Yes, I agree

Photo Release

I agree to let my student be photographed and/or videotaped during the activities of Germantown Presbyterian Church – GPConnect. I understand that pictures or recordings may be used for personal use, development of Germantown Presbyterian Church – GPConnect, slideshows, training purposes, and/or to help with promotion and/or fundraising.

Do you agree?*

I agree
I do not agree

If you have any questions, please contact Blair Hayes Director of GPC Kids, email: blairh@gpctn.org

GPConnect 2024-25

August 23 @ 6:00 pm - 9:00 pm

GPConnect -Registration - 2024-2025

Participant Information:

Additional Participants

Parent/Guardian's Information:

Liability Waiver

Photo Release

Details

Venue

GPConnect 2024-25

August 23 @ 6:00 pm - 9:00 pm

GPConnect -Registration - 2024-2025

Participant Information:

Additional Participants

Parent/Guardian's Information:

Liability Waiver

Photo Release

Details

Venue

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