Room Reservation Form

Child's information

Child's name*

First Last

Grade the child is entering this fall*

Child's gender*

Boy
Girl
Prefer not to answer

Child's birthday*

What medical concerns or allergies should we know about?*

Friend or adult you want the child to be with*

Note: If you're inviting a friend, we want to accomdoate as many of those relationships as we can. Must be in the same age group.

Your information

Your name*

First Last

Your relationship to the child*

Your address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your email*

Your phone number*

Emergency contact's information

Emergency contact's name*

First Last

Emergency contact's relationship to the child*

Emergency contact's phone number*

Digital signature for authorization for emergency medical action*

I, who by law may do so, authorize the administration of emergency medical treatment for the subject(s) of this release form. I understand that all reasonable safety precautions will be taken at all times by Evanston Vineyard, or its agents liable for any accident, injury or disease incurred by the subject of this form. I understand that, in the event medical intervention is needed, every attempt will be made to contact the person listed on this form immediately.

Digital initials for permission to use your child's photograph*

I give permission to Evanston Vineyard to photograph my child/dependent. I give permission to copyright, use, and publish the photographs for any lawful purpose, including but not limited to advertisements, newspaper articles, church publications, and the church website at the discretion of the program staff.