• Child's information

  • MM slash DD slash YYYY
  • 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

  • Emergency contact's information

  • 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.
  • 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.
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