I-Rock - International Bible Way

2015 I-ROCK Children’s Ministry Registration Form
INTERNATIONAL BIBLE WAY CHURCH OF JESUS CHRIST, INC
(Please Print)
STUDENT INFORMATION
Childs Full Name:
First Name
Last Name
Gender:  Girl  Boy
Childs Preferred Name:
Age:
Birth date:
T-Shirt Size (circle):
Middle Name
Youth or Adult -
Grade Entering in the fall:
X-Small / Small / Medium / Large / XL
PARENT / GUARDIAN INFORMATION
Name:
First Name
Last Name
Middle Name
Relationship to child:
Street Address:
City/State/Zip:
Hotel:
Cell Phone:
Room Number:
Alternate Phone:
Email Address:
Please list person(s) other than parent/guardian to contact in case of Emergency:
Name:
Primary Phone:
Relation:
Alternate Phone:
Other person(s) child(ren) authorized to be released to:
__________________________________________________________________ (Name) __________________________________________________________ (Phone)
__________________________________________________________________ (Name) __________________________________________________________ (Phone)
PARENT / GUARDIAN AGREEMENT
I give my child (ren) permission to participate in International Bible Way Church of Jesus Christ’s, Inc. a/k/a IBW, Children’s
Ministry hereinafter referred to as IROCK Children’s Ministry . I understand that my child will NOT be released to any
unauthorized person(s). However, my child has my permission to leave the site of the Convention or other IBW Meeting
wherever located, with authorized IROCK staff for scheduled trips and outings.
I agree that IBW and IROCK Children’s Ministry is released from any and all liability associated with the authorized medical
treatment, unauthorized emergency medical treatment, and accidents which happen while my child is under our care and
supervision. Further, agents of IROCK Children’s Ministry who are properly trained in emergency medical treatment such as
CPR, have my permission to use necessary medical measures in the event of an emergency.
I fully understand the inherent risks involved in the activities my child may be participating in. I accept all risks associated
with these activities and hold IROCK, IBW and authorized staff harmless for any injuries that may be sustained as a result of
my child (ren) participation in those activities.
Photo Waiver Form
I am aware that photographs of my child (ren) may be taken at IROCK Children’s Ministry.
I permit and authorize IROCK to use my child (ren) photograph or other likeness for purposes related to the mission of our
Organization, including publicity, marketing, and promotion of IBW and its various ministries. I understand that my
child(ren)’s photograph or likeness may be copied and distributed by means of various media, including video presentations,
television, news bulletins, mail outs, billboards or signs, brochures, placement on IBW websites or publications.
Photographs are considered the property of IBW and may not be sold or reused without the express consent of IBW.
________ I have read the foregoing Photo Waiver Disclaimer and agree to be bound by it.
________ I do not agree to the use of my child (ren) images in any of IBW’s communications.
________ I do not give permission for my child (ren) to be photographed, videotaped, or recorded.
I have read and agree to the fees, conditions, and policies outlined herein.
Parent/Guardian Signature
Date
OFFICE USE ONLY
Registration Fee PD
Method of payment
Deposit Amount
 Cash
 Check (Check No.)
Balance Due
 Money Order
Received By
Medical Information / Authorization Certification & Liability Release Form
Parent (or “Authorized Guardian”) must complete the following forms for each child participating in IROCK Children’s
Ministry. Please carefully read, complete below, and sign after providing the required information. If you have any questions
regarding this document, please contact Sharon Brown 516-728-6054.
Medical Information
(Please Print)
Child’s FULL NAME:
AGE:
Allergies to Medication(s): _________
_________________________________________________________________________________________________________________________
Food Allergies: _______________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
List of medications taken on a regular basis: ______________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Please indicate any significant health condition(s):
Health Insurance Provider:
Policy Number: ___________________________________________________________
_________
Group Number: _______________________________________
Policy Holder Name:
_________________________________________________
Contact Number: _____________________________________
Child’s Pediatrician:
Office Number: _______________________________________
Parent/Guardian Name:
Phone: __________
Authorization Certification and Liability Release
(Parent/Guardian Signature is required for child participation)
If my child
born
Becomes ill or involved in an accident, I authorize any medical treatment required. * PLEASE READ BELOW BEFORE SIGNING.
I give any representative of the International Bible Way Church or the I-ROCK Children’s Ministry permission to administer or
take my child for authorized treatment. I accept responsibility for any expenses incurred in the medical treatment of my child,
and assign all coverage to any health care provider from my health care plan(s) as noted above.
In consideration of the assistance of the Church Staff in organizing Children’s Ministry activities, I release the Church, all of its
personnel, any affiliates or assistants who function or accompany children on outings and activities, from any and all liabilities
or claims while my child goes to, attends, or returns from any Children’s Ministry activity; I assume all risks involved. This
“Release” is given on behalf of me, my child, and all family members.
Print Full Name:
Home Address (include city, state, zip)
Home Phone:
Cell Phone:
Parent/Guardian Signature:
Date:
WELCOME TO I-ROCK!!!
“Train up a child in the way he should go: and when he is old, he will not depart from it”. Proverbs 22:6
Hello Parents! First, we’d like to say that we are honored to be able to minister to your child this week. Please take a moment
and carefully read the following details regarding what you should expect. Your feedback is encouraged, so please let us know
if you have any questions, suggestions, or concerns.
WHAT DOES I-ROCK MEAN?
I-ROCK is an acronym that stands for I – Rule/Overcome/Care/Know! This ministry was designed to teach leadership skills
and community service to children ages 3-9yrs. Throughout this week, your child will learn practical lessons on Christian
character and leadership development.
HOURS OF OPERATION:
Monday - Friday: 9:00am – 4:00pm
STAFF CONTACT INFORMATION:
Sharon Brown
516-728-6054
Khaliah Taylor
201-344-7393
WHAT YOU CAN EXPECT:
 Daily devotion & workout (I-Move!)
 Biblical based teaching
 Lunch & snacks provided daily
 Self esteem and character building activities
 Educational trips and outings
 Learning Gods word in a fun and SAFE environment!
PARENT GUIDELINES:
1. For the safety of our children, each child must be signed IN and OUT each day.
2. All children must be fully toilet trained in order to participate. We understand that young children may have an
occasional accident; however we are not equipped to handle multiple accidents and diapering during our daily
activities. If a child has an accident during the day, we will notify the parent/guardian to pick up the child.
3. Please drop students off by 10:00 each day.
4. Children should be picked up on time each day. Children who are picked up late will be charged an additional fee of
$15 after the lateness. Late fees are due when lateness occurs.
5. Please dress children in comfortable clothing daily. We ask that children wear athletic shoes on days that we have
trips and outings.
6. On scheduled trips & outings, we ask that all children wear their I-ROCK signature T-shirt
7. Children who display severe disciplinary problems, causing danger or continual disruption to the program may be
removed from the program. No refunds will be given for children withdrawn or removed from the program early
(whether voluntarily or involuntarily).
I-ROCK CODE OF CONDUCT:
I-ROCK strives to offer an exceptional ministry experience for each child. We will model and enforce spiritual principles that
will help your child realize the greatness within. As an I-ROCK student, the following behavior standards will be expected
while in attendance. Please read and reiterate these rules with your child.
1. Honor God in all you do and say
Colossians 3:23 "Whatever you do, work at it with all your heart, as working for the Lord, not for men" NIV
2.
Be a Leader, not a follower
Romans 12:2 “Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern
what is the will of God, what is good and acceptable and perfect.” ESV
3. Always show respect for yourself and others
1 John 4:7 "Dear friends, let us love one another, for love comes from God” NIV
4. Keep hands, feet and objects to yourself
1 Corinthians 9:2 “I discipline my body and keep it under control” ESV
5. Always do your best!
Ecclesiastes 9:10 “Whatever your hand finds to do, do it with all your might” NIV
I-ROCK REGISTRATION CHECKLIST (Internal Use)
Completed by:
 Registration Form Completed
 Medical Information / Authorization Certification & Liability Release Form - Signed & Completed
 IROCK Guidelines & Code of Conduct (given to parent)
 Review Medical Information and discuss any food allergies or other medical concerns