NameThis field is for validation purposes and should be left unchanged.Family InformationPlease provide the household and parent/guardian contact information used for this registration.Family Last Name(Required)Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Home Phone NumberEmail Address(Required) Father's Name First Last Father's Phone NumberMother's Name First Last Mother's Phone NumberEmergency InformationEmergency Contact's Name(Required) First Last Emergency Contact's Phone Number(Required)Relationship to Child(Required)Registration AgreementsRegistration Fee(Required)Please confirm your understanding of the registration fee requirement. Yes, I understand. Waiver(Required)Cadets/Kingdom Seekers and all related activities at Pompton Plains Reformed Bible Church. I hereby give my consent for my minor child to participate in this activity. I also understand that my minor child is to be excluded from the following activities: ________________________________________ I understand that all reasonable safety precautions will be taken by the leaders of this activity, but that the possibility of an unforeseen hazard does exist. I further agree to indemnify and hold harmless Pompton Plains Reformed Bible Church, its leaders, employees, elders, deacons, and volunteer staff from any liability for damages, losses, diseases, or injuries incurred or sustained by the minor listed on this form, that might arise out of, en route to, en route from, while in residence, or as a result of any involvement or participation in activities sponsored by Pompton Plains Reformed Bible Church. I do hereby authorize any leaders for Pompton Plains Reformed Bible Church to authorize and consent to any x-ray examinations, anesthetic, medical or surgical procedures, based upon a diagnosis rendered and treatment recommended under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of any statutes authorizing the practice of medicine and/or dentistry and on the staff of any acute general hospital duly licensed to operate a hospital. It is understood 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 to render care which the aforementioned physician/medical professional in the exercise of their best judgment, may recommend in rendering treatment to the patient. All efforts will be made to contact me or others listed below, but I understand that any of the above treatment will not be withheld if attempted contact is not successful. Waiver, Hold Harmless and Authorization to Treat a MinorChildrenChoose the total number of children being registered. The form will display one child section for each child.How many children are you registering?(Required)Select 1-8 children12345678Child 1Enter this child’s registration and medical information.Child 1 Name(Required) First Last Child 1 Program / Group(Required)Select Cadets or Kingdom SeekersCadets (boys)Kingdom Seekers (girls)Child 1 Current Age(Required)Child 1 Grade(Required)Select gradePre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12OtherChild 1 AllergiesEnter “None” if the child has no known allergies.Does your child carry an Epi-pen? Yes No Child 1 Special Medications or Pertinent InformationList all special medications and any other information the leaders should know.Child 2Enter this child’s registration and medical information.Child 2 Name(Required) First Last Child 2 Program / Group(Required)Select Cadets or Kingdom SeekersCadets (boys)Kingdom Seekers (girls)Child 2 Current Age(Required)Child 2 Grade(Required)Select gradePre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12OtherChild 2 AllergiesEnter “None” if the child has no known allergies.Does your child carry an Epi-pen? Yes No Child 2 Special Medications or Pertinent InformationList all special medications and any other information the leaders should know.Child 3Enter this child’s registration and medical information.Child 3 Name(Required) First Last Child 3 Program / Group(Required)Select Cadets or Kingdom SeekersCadets (boys)Kingdom Seekers (girls)Child 3 Current Age(Required)Child 3 Grade(Required)Select gradePre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12OtherChild 3 AllergiesEnter “None” if the child has no known allergies.Does your child carry an Epi-pen? Yes No Child 3 Special Medications or Pertinent InformationList all special medications and any other information the leaders should know.Child 4Enter this child’s registration and medical information.Child 4 Name(Required) First Last Child 4 Program / Group(Required)Select Cadets or Kingdom SeekersCadets (boys)Kingdom Seekers (girls)Child 4 Current Age(Required)Child 4 Grade(Required)Select gradePre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12OtherChild 4 AllergiesEnter “None” if the child has no known allergies.Does your child carry an Epi-pen? Yes No Child 4 Special Medications or Pertinent InformationList all special medications and any other information the leaders should know.Child 5Enter this child’s registration and medical information.Child 5 Name(Required) First Last Child 5 Program / Group(Required)Select Cadets or Kingdom SeekersCadets (boys)Kingdom Seekers (girls)Child 5 Current Age(Required)Child 5 Grade(Required)Select gradePre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12OtherChild 5 AllergiesEnter “None” if the child has no known allergies.Does your child carry an Epi-pen? Yes No Child 5 Special Medications or Pertinent InformationList all special medications and any other information the leaders should know.Child 6Enter this child’s registration and medical information.Child 6 Name(Required) First Last Child 6 Program / Group(Required)Select Cadets or Kingdom SeekersCadets (boys)Kingdom Seekers (girls)Child 6 Current Age(Required)Child 6 Grade(Required)Select gradePre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12OtherChild 6 AllergiesEnter “None” if the child has no known allergies.Does your child carry an Epi-pen? Yes No Child 6 Special Medications or Pertinent InformationList all special medications and any other information the leaders should know.Child 7Enter this child’s registration and medical information.Child 7 Name(Required) First Last Child 7 Program / Group(Required)Select Cadets or Kingdom SeekersCadets (boys)Kingdom Seekers (girls)Child 7 Current Age(Required)Child 7 Grade(Required)Select gradePre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12OtherChild 7 AllergiesEnter “None” if the child has no known allergies.Does your child carry an Epi-pen? Yes No Child 7 Special Medications or Pertinent InformationList all special medications and any other information the leaders should know.Child 8Enter this child’s registration and medical information.Child 8 Name(Required) First Last Child 8 Program / Group(Required)Select Cadets or Kingdom SeekersCadets (boys)Kingdom Seekers (girls)Child 8 Current Age(Required)Child 8 Grade(Required)Select gradePre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12OtherChild 8 AllergiesEnter “None” if the child has no known allergies.Does your child carry an Epi-pen? Yes No Child 8 Special Medications or Pertinent InformationList all special medications and any other information the leaders should know.PaymentTotal Number of Children to Pay for Online Price: $0.00 Total Credit Card(Required)