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Participant Registration

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Registro en Español

Gateway Fellowship

Location

18901 8th Ave NE

Poulsbo, WA 98370

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Contact Michelle Bruneau:

360-779-5515

michelle.bruneau@gatewayfellowship.com

First, Tell Us About Yourself:

Parent Information

First Name

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Last Name

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Address 1

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Address 2

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City

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State/Province

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ZIP/Postal Code

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Contact Phone 1

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Contact Phone 2

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Emergency Contact Name

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Emergency Contact Relationship

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Emergency Contact Phone

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Alternate Pickup Name

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Alternate Pickup Phone

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Alternate Pickup 2 Name

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Alternate Pickup 2 Phone

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LIABILITY RELEASE for GATEWAY FELLOWSHIP

I ACKNOWLEDGE BY TYPING MY NAME IN THE BOX BELOW that my child has the privilege of joining the Day Camp children's programs at Gateway Fellowship. We are pleased to offer your child this opportunity. Your encouragement in proper conduct would be appreciated. Adult supervision and care will be provided at all times.

In the event my child becomes ill or sustains injury while in the care of, or under the supervision of Gateway Fellowship, or any of its officers or leaders they are given permission to administrate First Aid for his/her relief. If it is not practical to return him/her to us, or to receive our instructions for his/her care, consent is hereby given to admit him/her to any hospital. Consent is also given to any licensed physician and/or surgeon called, or to whom our son/daughter is taken for treatment by them to administer such treatment, drugs, and medicines, and to perform such surgical procedures as he/she shall think the existing emergency requires for the relief of pain and to preserve his/her life and health. Authorization is also given for such other measures or procedures as may be required.

I also acknowledge by signing I am giving permission for my child's picture to be taken and used by Gateway Fellowship.

[If you have a child whose picture cannot be used for safety reasons, i.e. foster child, please email Shelly Cole with the child's name, reason for no picture, and a picture for our reference.

shelly.cole@gatewayfellowship.com

Please enter your FULL legal name below.

Full Legal Name

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Click here for your FREE Friends With God Kids Activity Pack

By checking the box you will be emailed your Free Friends With God Kids Activity Pack.

You are also agreeing to receive emails about family resources from Lifetree. You can unsubscribe at any time. We value your privacy. Your information will not be shared with a third party. Lifetree is a division of Group Publishing, the creators of Group VBS and other faith-building resources. Click to learn more about Lifetree.

Tell Us About Your Participant

First Name

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Last Name

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Grade Entering

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Gender

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Date Of Birth

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Allergies

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Medical Concerns

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Do you have friends you would like to be placed with? We will do our best to group selected friends together in the same crew, but we cannot promise all requests will be possible.

Friend 1 First Name

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Friend 1 Last Name

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Friend 2 First Name

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Friend 2 Last Name

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Friend 3 First Name

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Friend 3 Last Name

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Comments

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