Danvers Baptist Church

Summer Blast 2024

Ages: K4-5th Grade

Child's Information

Child's First Name

Last Name

Grade This Fall

Age

Gender

Allergies, Medical, Special Needs

Were you invited by someone? If so let us know who below.

Parent/Guardian Information

Parent/Guardian First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone/Text

Email

I give consent for photographs/videos of the children named above taken during this program to be used for promotional purposes of Danvers Baptist Church.
Permission to Attend: I give permission for the children named above to attend and participate in all activities of SUMMER BLAST at Danvers Baptist Church and our neighboring property at 105 N West St, Danvers.
Medical Release: I authorize the executive staff or designated medical professionals to administer emergency medical assistance in the event that I cannot be reached. I understand that the SUMMER BLAST staff will contact emergency services in the event of a significant injury and that all expenses for such emergency services will be paid by me, the parent or guardian. I further understand that in signing this form, I release and hold harmless Danvers Baptist Church, its pastor, directors, officers, employees, and any volunteers from any liability, past or future, fully and completely.

Signature

Danvers Baptist Church
104 W. Columbia | PO Box 375 | Danvers, IL 61732 | 309.963.4627
www.danvers.church