Club 345 - Spring 2026

Name of Child

Grade

3rd 4th 5th

Name of School

If your child goes to Valentine Elementary: would you like Mrs. Natalie to pick up your child on Club 345 meeting days? Yes, at 2:30 PM Yes, at 2:50 PM No, they can walk/bike over by themselves.

Gender

Female Male

Date of Birth

Parent/Guardian

Parent/Guardian Email

This address will receive a confirmation email

Address

Phone

Emergency Contact

Emergency Contact Relationship

Emergency Contact Phone

Health or Special Needs (check as appropriate)

My son/daughter has no special health needs that the staff should be aware of and is not on any kind of medication. My son/daughter has the following special need(s) or health concerns:

Special Needs and/or Health Concerns:

Donations are welcome to help offset the costs of supply needs. Thank you! (Please scroll down to the bottom for payment information)

Parents will be asked to provide snacks for the group once per semester. Please open a new tab and sign up for a date at Snack Sign-up, then come back and finish this form.

RELEASE FOR PARTICIPATION: I, the undersigned participant and/or parent or guardian of the minor participant, give my permission to have images taken at San Marino Community Church events used, without recompense, to promote the Children’s Ministry and SMCC. Names will never be used without parental permission. We realize that no activity is without the possibility of unforeseen hazards which could result in injury to an individual. As a parent or guardian, you are to be aware of your responsibility to instruct your child on the importance of conduct which will ensure safety and enjoyable time while participating in this activity. By signing this form, you, as a parent, guardian, or other responsible parties, agree to assume the risks and hazards which are inherent in this kind of activity. You also agree to absolve and hold harmless the sponsoring organizations and their representatives for damage, loss, or injuries to the child for whom you sign. I certify that I am the parent or legal guardian of the participant named; that I have read and understood the foregoing release; and that I join in the release without reservation, granting full consent and authorization for my child to participate in the activity. My electronic signature is in the box below:

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Club 345 - Spring 2026

Description

Please Fix the Following