Child Name *

First Name

Last Name

Parent Name *

First Name

Last Name

Parent Phone Number *

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Opt Out of Media Release

By registering your child you give Dtour Youth Ministry permission to use your child’s photograph(s) publicly to promote Dtour. The image(s) may be used in print publications, online publications, presentations, websites, and social media. You agree that no royalty, fee or other compensation shall become payable to you by reason of such use. Check this box if you DO NOT CONSENT to the use of your child's image in association with our ministry.

Dtour does NOT have my permission to use my child's photo

Arrival *

Please check all that apply

My child may walk to Dtour

My child may be dropped off

My child may ride the bus to Dtour

Departure *

Please check all that apply

My child may walk home

My child may be picked up by an approved individual listed below

My child may ride in the Dtour Activity Vehicle to the School to catch the activity bus

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Medical Authorization *

If a child is in need of emergency medical care while attending Dtour, we will call the parent/guardian immediately, and will also seek appropriate emergency medical care. To allow us to seek appropriate medical care, please check the box below:

I authorize Dtour program personnel to seek emergency medical treatment for my child if necessary.

Date *

Today's date

MM

DD

YYYY