This document appears to be a registration form collecting personal information about multiple children, their family, medical details, and photo/travel permissions. It requests the names, grades, schools, dates of birth, medical conditions, and shirt sizes of up to four children. It also asks for the parents' contact details, insurance information, emergency contacts, and signatures to authorize participation in activities and release the church from liability.

1. Child #1<br />Name FORMTEXT Shirt Size FORMDROPDOWN FORMDROPDOWN Grade (as of September, 2010) FORMDROPDOWN School FORMTEXT Date of Birth FORMTEXT Please describe any medical conditions, allergies, medications, social, behavioral concerns or special needs FORMTEXT <br />Child #2<br />Name FORMTEXT Shirt Size FORMDROPDOWN FORMDROPDOWN Grade (as of September, 2010) FORMDROPDOWN School FORMTEXT Date of Birth FORMTEXT Please describe any medical conditions, allergies, medications, social, behavioral concerns or special needs FORMTEXT <br />Child #3<br />Name FORMTEXT Shirt Size FORMDROPDOWN FORMDROPDOWN Grade (as of September, 2010) FORMDROPDOWN School FORMTEXT Date of Birth FORMTEXT Please describe any medical conditions, allergies, medications, social, behavioral concerns or special needs FORMTEXT <br />Child #4<br />Name FORMTEXT Shirt Size FORMDROPDOWN FORMDROPDOWN Grade (as of September, 2010) FORMDROPDOWN School FORMTEXT Date of Birth FORMTEXT Please describe any medical conditions, allergies, medications, social, behavioral concerns or special needs FORMTEXT <br />Address FORMTEXT City FORMTEXT State FORMTEXT Zip FORMTEXT Mother’s Name FORMTEXT Father’s Name FORMTEXT Home Phone # FORMTEXT Cell Phone # FORMTEXT Email Address #1 FORMTEXT Email Address #2 FORMTEXT <br />Emergency Contact<br />Name FORMTEXT Phone # FORMTEXT Relationship FORMTEXT <br />Medical and Health Insurance Information<br />Doctor’s Name FORMTEXT Phone # FORMTEXT Address FORMTEXT Insurance Carrier FORMTEXT Policy # FORMTEXT Policy Holder FORMTEXT Hospital Preference FORMTEXT <br />Photography Authorization<br />May we take pictures or video of your child(ren) for use on our website, newsletter, local newspapers or other media outlets?<br /> FORMCHECKBOX Yes FORMCHECKBOX No<br />I; the undersigned, parent or guardian of the child, hereby give my approval for my child to participate in activities and trips with Conshohocken United Methodist Church. I, the undersigned, assume the risks and hazards incidental in the nature of activities and trips. I, the undersigned, hereby for myself, my child, my heirs, executors and administrators, release, absolve, indemnify, and hold harmless Conshohocken United Methodist Church. The United Methodist Conference, all volunteers and paid staff, for all injuries sustained or caused as a result of the program and all of its related activities.<br />Signed: Date: <br />