print and mail this form with your check to
Gloria Dei Lutheran Church
8301 Aurora Avenue
Urbandale IA 50322
Kindermusik Registration 2006 Form
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Family Time !
Family Time offers families an opportunity to play, sing and move with their children. This multi-age child setting offers something for everyone! This fun class runs for 10 weeks, beginning September 12 or September 13.
- Tuesday evening class meets from 6:30-7:15 pm.
- Or Wednesday morning class meets from 10:00-10:45 am.
- The class fee is $90 for all 10 weeks; the class fee includes materials for use at home
Imagine That!
Imagine That! is a music and movement class for children ages 3, 4 & 5. Each session delights the whole child as we sing, move, play instruments, and discover more about the world in which we live! This fun class runs for 14 weeks, beginning September 12.
- Tuesday evening class meets from 6:30-7:15 pm.
- The class fee is $110 for all 14 weeks; the class fee includes materials for use at home.
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Gloria Dei Lutheran Church
Medical Information Form
Children’s/Youth Activities
Name of Kindermusick Class____________________ Date of Class______________________
Child's Name _______________________________________________________________
Address _______________________________ City_____________ State_______ Zip _______
Date of Birth __________ Age______ Sex ______ Grade in School _________________
Mother’s Name _____________________ Father’s Name ______________________________
Home Phone ___________________ Daytime Phone _____________________
Mother’s Cell Phone _______________ Work Phone _________________________________
Father’s Cell Phone __________________ Work Phone _______________________________
Name of two alternates who may be contacted in case of emergency:
1. Name______________________________ Relationship ___________________________
Daytime Phone________________________ Evening Phone_________________________
2. Name______________________________ Relationship __________________________
Daytime Phone________________________ Evening Phone ________________________
I verify that the above medical information on my child is complete and accurate. My child will not attend if not feeling well. I understand that I will be notified as soon as possible in case of an emergency. In the event I cannot be reached in an emergency, I hereby authorize the calling of a physician at my expense to provide whatever emergency medical treatment is necessary.
I understand and certify that my child’s participation in Gloria Dei Lutheran Church’s children’s/Youth Programs is completely voluntary. I have familiarized myself with the activities in which my child/youth will be participating. I recognize that certain hazards and dangers are inherent to the children’s/youth programs. I acknowledge that although Gloria Dei Lutheran Church and it’s children’s/Youth Leaders have taken safety measures to minimize risk of injury to children/youth group participants, Gloria Dei Lutheran Church cannot insure nor guarantee that the participants, equipment, premises, and/or activities will be free of hazard, accidents and/or injuries.
Signed___________________________________Date_________________________________
I authorize and give exclusive permission to Gloria Dei Lutheran Church to use photos, audiotape, or videotape of the below stated minor child(ren) for the promotion of current or future church programming and any publicity efforts of any kind directly related to Gloria Dei Lutheran Church. I understand that any photograph, audiotape, or videotape will only be used for non-profit activity. By signing this document I understand the terms and conditions set forth herein.
Name of Minor Child(ren) __________________________________________________
Signature of Parent/Legal
Guardian___________________________________________
Printed Name of Parent/Legal
Guardian________________________________________ Date_________________________________
Please write the check number and the amount ____________________ |
