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Replanted Childcare Registration Form 2022
Parent or Legal Guardian Information
Childcare is subjected to volunteer availability and not guaranteed.
MM slash DD slash YYYY
Relationship with Child
Please check all that apply:
Please select what day(s) you would like childcare services:
We encourage and invite you to attend both days. If both days are not feasible, please indicate which day you will be attending.
Friday, October 14th
Saturday, October 15th
Emergency Person (other than above)
Emergency Person Relationship
Emergency Person Phone
Name & Phone of Primary Physician
Health Policy Number
What county do you live in?
Contra Costa County
San Francisco County
San Mateo County
Santa Clara County
Have you attended a Help One Child event before?
How did you find out about this event?
As a new family, we'd like to contact you to start the process of registering with Help One Child.
What's the best way to get in touch with you?
How many Kids will you need childcare for?
Child #1 Name
Child #1 Age
Child #2 Name
Child #2 Age
Child #3 Name
Child #3 Age
Child #4 Name
Child #4 Age
Child #5 Name
Child #5 Age
Child #6 Name
Child #6 Age
Do any of the kids signed up for childcare have any known medical issues or allergies we should be made ware of?
Please include the child's name and medical issue or allergy.
Any additional comments or concerns?
HOC Waiver and Release: Permission Form for Minors
I, the undersigned parent, legal guardian, or foster parent of the above-named Minor(s), hereby give my permission for my child(ren)’s participation in Replanted Conference Childcare held at Peninsula Bible Church Palo Alto on October 14th & 15th, 2022. (the “Event”).
In signing this form, I warrant and represent that I am the parent, legal guardian, or foster parent, that I am 18 years of age or older; and I indemnify and hold harmless, release and discharge Help One Child, Replanted Conference Childcare and Peninsula Bible Church Palo Alto and their constituent organizations, officers, agents, employees, and volunteers from any and all claims for personal injuries, property damage or wrongful death that my child may suffer as a result of his/her participation in the activity described above, whether or not such injuries or damages are caused by the negligence (active or passive) of any of the entities or individuals named or described above.
I agree that in the event my child is injured as a result of his/her participation in the above-named activities, including transportation to and from these activities, recourse for the payment of any hospital, medical, dental, or related costs and expenses will be paid either by me or my spouse, accident, hospital or medical insurance, or any available benefit plan of mine or my spouse.
I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician, surgeon, or dentist licensed under the Medical Practice Act and Dental Practice Act. As parent, legal guardian, or foster parent, I am responsible for the health care decisions of my child and am authorized to consent to services to be rendered, and law requires no other consent.
I hereby give permission to the physician selected by the Activity supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician or dentist.
I hereby authorize the making of photographs, motion pictures, videotapes, recordings, or other memorializing of said event and his/her participation therein. In any photos no identifiable features or information (name or face) will be shown.