Participant Registration

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Harvest Valley Church

Location

743 Winter Creek Drive

Scottsbluff, NE 69361

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Contact Adam Sanders:

918-617-1225

adamsanders.harvestvalleychurch@gmail.com

First, Tell Us About Yourself:

Parent Information

Name of sponsoring organization: Harvest Valley Church

Address: 743 Winter Creek Drive, Scottsbluff, NE

Phone: 308-632-2543

Name of sponsor's coordinators:

Adam Sanders Phone: 918-617-1225

Joel Hergert Phone: 503-779-3657

Description of Activity: Mid-week children's ministry for Preschool through 5th Grade.

Dates and location of activity: September 4, 2024 through April 30, 2025 at Harvest Valley Church

If your child has divorced/separated parents, please list both parents and phone numbers so the staff will have the name of the parents for the child/children.

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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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.

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Tell Us About Your Participant

If your child has divorced/separated parents, please list both parents and phone numbers so the staff will have the name of the parents for the child/children.

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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Comments

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Medical Authorization: Is sponsor authorized to approve medical treatment, if the needed? Yes or No

Multiple selections are allowed.

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Photo Authorization: May we post pictures of your child on social media platforms or our website? Yes or No

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Participation Agreement: I acknowledge that participation in the activity described above involves risk to the participant (and to the participant's parents or guardians, if the participant is a minor,) and may result in various types of injury including but not limited to, the following: sicknss, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage and financial damage. In consideration for the opportunity to participate in the activity described above (the "activity"), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in the activity. The participant (or parent/guardian) accepts financial responsibility for any injury during the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents,, employees, volunteers, or any other representatives (collectively referred to as the "activity sponsor"). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through mutually acceptable dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree with such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.

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If you agree to the conditions set forth in the Participation Agreement, please click yes. If you are completing a paper registration please sign your name below.

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