Kids for Peace Member Registration Form

Thank you for signing up your child to become a member of Kids for Peace! We are so happy you are here!

Youth Member's Info

Please provide the details for the Youth Member below.
To register more than one child, please click the 'Register Another Youth Member' link.

Youth Member's Chapter Name:

If other, please provide Chapter Name:

I am:

Registering for the 1st timeRe-Registering

Youth Member's First Name

Youth Member's Last Name

Youth Member's Date of Birth:

Month

Day

Year

School Name:

Grade:

We encourage you to voluntarily provide the below information on racial background. This information will be used by Kids for Peace to improve our outreach efforts.

Youth Member's T-Shirt Size

If you are registering more than one Youth Member,

please click the link to the right.

Guardian's Info

Guardian's First Name

Guardian's Last Name

Relationship to Youth Member

Mobile Phone Number

Other Phone Number

Emergency Contact Info

Emergency Contact First Name

Emergency Contact Last Name

Relationship to Youth Member

Emergency Contact Phone Number

Physician's Full Name

Physician's Phone Number

Please list any medical conditions or special dietary needs

Payment Information

Name on Card

Card Number

Code

Billing Email

Billing Address

First Name

Last Name

Address Line 1

Address Line 2

City

State

Postal Code

Is your shipping address different than your billing address?

YesNo

Shipping Address

First Name

Last Name

Address Line 1

Address Line 2

City

State

Postal Code

Country

Parental/Guardian Consent

Parental/Guardian Consent must be signed for child(ren) to participate in Kids for Peace programs.

Kids for Peace, Inc. is a non-profit designed to provide opportunities to engage every child in every nation with the experience of cross-cultural friendship, giving and receiving kindness and engaging in service which brings peace to their communities and to our world. Participants engage in hands-on art, community service and environmental projects, workshops, and field trips. By signing below, you acknowledge the goals of the program and grant permission for your child to participate.

As parent/guardian of the minor participant(s) listed above, I, hereby give my approval for his/her participation in any and all Chapter activities. I assume all risk and hazards incidental to such participation, and I do hereby waive, release, absolve, indemnify, hold harmless, and forever discharge the non-profit Kids for Peace, Inc., its officers, staff, Chapter Leaders, and all persons involved directly or indirectly with said activities, from any claim, liability, demands, actions, and/or causes of action arising out of or related to any loss, property damage, and/or personal injury/death, that may be sustained by me or my child while participating in a Kids for Peace, Inc. activity and/or event.

I further understand that Kids for Peace, Inc. does not carry medical insurance for the participants. I understand that I will be required to rely on private medical and hospitalization insurance for any injuries that the child may incur as a result of their participation in this program.

I have read the above terms of this consent form, and I understand and voluntarily agree to the terms and conditions. This agreement shall be binding on myself, the minor participant(s) heirs and personal representatives.

Parent's / Guardian's Signature

Date

*By typing your name in the Signature field, you are indicating your acceptance of this agreement and your typed name and submission of this application to Kids for Peace will be treated as an original, written signature.

Release to Photograph

I, Parent/Guardian of above listed child(ren), understand that Kids for Peace, Inc. may take still photos and/or videotape of my child while they are participating in an event, project, or activity.

I grant Kids for Peace, Inc. and its designees the right to use my child/children’s name, likeness, image, voice, appearance, and performance whether recorded or provided on or transferred to videotape, film, slides, photo- graphs, audiotapes, or other media, now known or later developed. This permission includes without limitation the right to edit, mix or duplicate, resize or crop and to use or re-use the photo and/or video tape in whole or part as Kids for Peace may elect for promotional campaigns, newspaper articles, brochures, grants, or any other program or product. This includes the right to broadcast, exhibit, market and otherwise distribute the photos and/or video tape without any financial commitment or obligations to me as a result of this agreement. I expressly release and indemnify Kids for Peace, Inc. and its officers, employees, agents and designees from any and all claims known and unknown arising out of, or in any way connected with the above granted uses and representations.

Parent's / Guardian's Signature

Date

Consent and Authorization to Treat a Minor

In the event of injury or illness, or other emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby authorize the adult leader to secure or provide emergency medical treatment, including hospitalization, anaesthesia, surgery or other medical care, and I hereby assume the cost of such treatment. I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervising adult to give specific consent to the diagnosis, treatment, or hospital care which in the best judgment of a medical professional is deemed advisable.

Parent's / Guardian's Signature

Date

I read and agree with the Privacy Policy.I would like receive Kids for Peace newsletters. You can unsubscribe at any time from a link in the newsletter.

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