M&M Registration – Valencia Presbyterian Church

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About
Worship
- Weekly Services
- Prayer Requests
Ministries
Calendar & Events
Giving
Links
Contact

Mommy & Me Registration

Child's First Name:

Child's Last Name:

Age:

Birthdate:

Gender:

Parent's First Name:

Parent's Last Name:

Address:

City:

State:

Zip:

Primary Phone #:

Secondary Phone #:

Email:

Any Allergies or Medical Conditions we should be aware of?

Yes No

Explanation of Allergies or Medical Condition:

Name of Adult Attending with Child (if different than above):

Phone # (if different than above):

Relationship to Child:

I am registering for:

All 10 Classes ($90)

I am registering for the following individual classes ($10 per class):

Sept. 6 Sept. 13 Sept. 20 Sept. 27 Oct. 4 Oct. 11 Oct. 18 Oct. 25 Nov. 1 Nov. 8

Health/Safety Guidelines

In order to keep all participants healthy and safe, I understand that participants should not attend this event if they are experiencing a cough, fever, shortness of breath or have had exposure to Covid-19 .

Liability and Medical Release

While attending this program at Valencia Presbyterian Church, I release the Valencia Presbyterian Church and its employees/volunteers from all liability for any injury that may occur while on the premises at this time. I hereby authorize Valencia Presbyterian Church to administer basic First Aid to myself or my child and to seek professional medical treatment if necessary.

Publicity

On occasion, Valencia Presbyterian Church may take photographs or make an audio or video recording of participants involved in church activities to be used as an event keepsake or in publications or advertising materials to let others know about our ministry. No names or identifying information is released. I consent to the use of any such audio or visual record of myself/my child to be used as the church sees fit.

Valencia Presbyterian Church
80 Sterrett Street
Valencia, PA 16059
Office: (724) 625-2002
Fax: (724) 625-3137
vpc@valenciapresbyterian.com

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Mommy & Me Registration

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