Word of Life Online Registration

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" background="abdfd5a3.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B> Grace Evangelical Church </B></FONT><B>    </B><B> |     </B><A HREF="index.htm" TARGET="_top" TITLE=" Grace Evangelical Church "><U><B>home</B></U></A></div> <div>                                                   </div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="b23d2b03.jpg"> <bR> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Word of Life Online Registration</I></div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> Word of Life Online Registration!</div> <bR> <div> 7:00pm on Wednesday nights</div> <div> September 14th is "Parent Night" and in Ice Cream Social</div> <div> Word of Life Bible Club starts September 21st.</div> <bR> <bR> <div>    <form enctype="multipart/form-data" method="post" action="http://www.response-o-matic.com/mail.php" accept-charset="UTF-8"> <div> <input type="hidden" name="acctid" id="acctid" value="v49cez7zhol6bvnl" /> <input type="hidden" name="formid" id="formid" value="417106" /> <input type="hidden" name="required_vars" id="required_vars" value="name,field-47a139539d27644,email,field-83382e5a01667bc,field-6e8f7f767af2e08,field-4d376587ff22046,field-a0f5be18c6e2ae2,field-29551acaed68881,field-8d722013319578f" /> </div> <table cellspacing="5" cellpadding="5" border="0"> <tr> <td valign="top"> <strong>Parent/Guardian Name:</strong> </td> <td valign="top"> <input type="text" name="name" id="name" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Address (include city and zip code):</strong> </td> <td valign="top"> <textarea name="field-47a139539d27644" id="field-47a139539d27644" rows="6" cols="40"></textarea> </td> </tr> <tr> <td valign="top"> <strong>Email Address:</strong> </td> <td valign="top"> <input type="text" name="email" id="email" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Home Phone</strong> </td> <td valign="top"> <input type="text" name="field-83382e5a01667bc" id="field-83382e5a01667bc" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Cell Phone</strong> </td> <td valign="top"> <input type="text" name="field-305af013f6d461e" id="field-305af013f6d461e" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Emergency Contact (list name/phone number of 2 people):</strong> </td> <td valign="top"> <textarea name="field-6e8f7f767af2e08" id="field-6e8f7f767af2e08" rows="6" cols="40"></textarea> </td> </tr> <tr> <td valign="top"> <strong>If in preschool, who may pick up your child(ren)?</strong> </td> <td valign="top"> <textarea name="field-de4cbf781c01c81" id="field-de4cbf781c01c81" rows="6" cols="40"></textarea> </td> </tr> <tr> <td valign="top"> <strong>What church, if any, do you attend?</strong> </td> <td valign="top"> <input type="text" name="field-9ae1d56bb897fe4" id="field-9ae1d56bb897fe4" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>I agree to the Authorization/Consent Form at the bottom of page.</strong> </td> <td valign="top"> <input type="checkbox" name="field-4d376587ff22046[]" id="field-4d376587ff22046_0" value="I agree" /> I agree<br/> </td> </tr> <tr> <td valign="top"> <strong>1st Child's Name:</strong> </td> <td valign="top"> <input type="text" name="field-a0f5be18c6e2ae2" id="field-a0f5be18c6e2ae2" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>1st Child's age:</strong> </td> <td valign="top"> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_0" value="3" /> 3<br/> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_1" value="4" /> 4<br/> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_2" value="5" /> 5<br/> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_3" value="6" /> 6<br/> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_4" value="7" /> 7<br/> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_5" value="8" /> 8<br/> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_6" value="9" /> 9<br/> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_7" value="10" /> 10<br/> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_8" value="11" /> 11<br/> <input type="radio" name="field-29551acaed68881" id="field-29551acaed68881_9" value="12" /> 12<br/> </td> </tr> <tr> <td valign="top"> <strong>1st Child's Date of Birth (MM/DD/YYYY):</strong> </td> <td valign="top"> <input type="text" name="field-8d722013319578f" id="field-8d722013319578f" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>1st Child's last grade completed (if not a preschooler):</strong> </td> <td valign="top"> <input type="radio" name="field-792540f8c512ea4" id="field-792540f8c512ea4_0" value="Kindergarten" /> Kindergarten<br/> <input type="radio" name="field-792540f8c512ea4" id="field-792540f8c512ea4_1" value="1st" /> 1st<br/> <input type="radio" name="field-792540f8c512ea4" id="field-792540f8c512ea4_2" value="2nd" /> 2nd<br/> <input type="radio" name="field-792540f8c512ea4" id="field-792540f8c512ea4_3" value="3rd" /> 3rd<br/> <input type="radio" name="field-792540f8c512ea4" id="field-792540f8c512ea4_4" value="4th" /> 4th<br/> <input type="radio" name="field-792540f8c512ea4" id="field-792540f8c512ea4_5" value="5th" /> 5th<br/> </td> </tr> <tr> <td valign="top"> <strong>Medical or other information we need to know. (Please include food allergies.)</strong> </td> <td valign="top"> <textarea name="field-e946ac07d4a763b" id="field-e946ac07d4a763b" rows="6" cols="40"></textarea> </td> </tr> <tr> <td valign="top"> <strong>2nd Child's Name:</strong> </td> <td valign="top"> <input type="text" name="field-5a17ef67e8641dc" id="field-5a17ef67e8641dc" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>2nd Child's age:</strong> </td> <td valign="top"> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_0" value="3" /> 3<br/> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_1" value="4" /> 4<br/> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_2" value="5" /> 5<br/> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_3" value="6" /> 6<br/> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_4" value="7" /> 7<br/> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_5" value="8" /> 8<br/> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_6" value="9" /> 9<br/> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_7" value="10" /> 10<br/> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_8" value="11" /> 11<br/> <input type="radio" name="field-6f4060b405d10cc" id="field-6f4060b405d10cc_9" value="12" /> 12<br/> </td> </tr> <tr> <td valign="top"> <strong>2nd Child's Date of Birth (MM/DD/YYYY):</strong> </td> <td valign="top"> <input type="text" name="field-0f9978e9e1eeff4" id="field-0f9978e9e1eeff4" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>2nd Child's last grade completed (if not in preschool):</strong> </td> <td valign="top"> <input type="radio" name="field-2ab3fc7a91160b8" id="field-2ab3fc7a91160b8_0" value="Kindergarten" /> Kindergarten<br/> <input type="radio" name="field-2ab3fc7a91160b8" id="field-2ab3fc7a91160b8_1" value="1st" /> 1st<br/> <input type="radio" name="field-2ab3fc7a91160b8" id="field-2ab3fc7a91160b8_2" value="2nd" /> 2nd<br/> <input type="radio" name="field-2ab3fc7a91160b8" id="field-2ab3fc7a91160b8_3" value="3rd" /> 3rd<br/> <input type="radio" name="field-2ab3fc7a91160b8" id="field-2ab3fc7a91160b8_4" value="4th" /> 4th<br/> <input type="radio" name="field-2ab3fc7a91160b8" id="field-2ab3fc7a91160b8_5" value="5th" /> 5th<br/> </td> </tr> <tr> <td valign="top"> <strong>Medical or other information we need to know. (Please include food allergies.)</strong> </td> <td valign="top"> <textarea name="field-fd2d3d049898c68" id="field-fd2d3d049898c68" rows="6" cols="40"></textarea> </td> </tr> <tr> <td valign="top"> <strong>3rd Child's name:</strong> </td> <td valign="top"> <input type="text" name="field-b7d9045ad4e709c" id="field-b7d9045ad4e709c" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>3rd Child's age:</strong> </td> <td valign="top"> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_0" value="3" /> 3<br/> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_1" value="4" /> 4<br/> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_2" value="5" /> 5<br/> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_3" value="6" /> 6<br/> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_4" value="7" /> 7<br/> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_5" value="8" /> 8<br/> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_6" value="9" /> 9<br/> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_7" value="10" /> 10<br/> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_8" value="11" /> 11<br/> <input type="radio" name="field-dfd094a89a3857c" id="field-dfd094a89a3857c_9" value="12" /> 12<br/> </td> </tr> <tr> <td valign="top"> <strong>3rd Child's Date of Birth (MM/DD/YYYY):</strong> </td> <td valign="top"> <input type="text" name="field-3e9f859e859e910" id="field-3e9f859e859e910" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>3rd Child's last grade completed (if not in preschool):</strong> </td> <td valign="top"> <input type="radio" name="field-339dc534fc965ff" id="field-339dc534fc965ff_0" value="Kindergarten" /> Kindergarten<br/> <input type="radio" name="field-339dc534fc965ff" id="field-339dc534fc965ff_1" value="1st" /> 1st<br/> <input type="radio" name="field-339dc534fc965ff" id="field-339dc534fc965ff_2" value="2nd" /> 2nd<br/> <input type="radio" name="field-339dc534fc965ff" id="field-339dc534fc965ff_3" value="3rd" /> 3rd<br/> <input type="radio" name="field-339dc534fc965ff" id="field-339dc534fc965ff_4" value="4th" /> 4th<br/> <input type="radio" name="field-339dc534fc965ff" id="field-339dc534fc965ff_5" value="5th" /> 5th<br/> </td> </tr> <tr> <td valign="top"> <strong>Medical or other information we need to know. (Please include food allergies.)</strong> </td> <td valign="top"> <textarea name="field-f8721b1f8d3d4d3" id="field-f8721b1f8d3d4d3" rows="6" cols="40"></textarea> </td> </tr> <tr> <td valign="top"> <strong>Please list any specific placement requests (other children you want to be together with in same group):</strong> </td> <td valign="top"> <textarea name="field-901c261df1efe2d" id="field-901c261df1efe2d" rows="6" cols="40"></textarea> </td> </tr> <tr> <td colspan="2" align="center"> <input type="submit" value=" Submit Form " /> </td> </tr> </table> </form> <br><center><font face="Arial, Helvetica" size="1"><b> This <a href="http://www.response-o-matic.com">contact form</a> was created by Freedback. </b></font></center>   </div> <div> If you have more than 3 children to register, hit "submit" and then go back and register the remaining children.</div> <div> You are also invited to register your child in the lobby any Wednesday evening or Sunday morning.</div> <bR> <bR> <div> <B>ATTENTION PARENTS: </B></div> <div> Please read and agree to the following prior to registering your child.  By registering your child online, it is understood that you have read and agree to the following <I><B>Authorization and Consent Form</B></I>.</div> <bR> <div> This consent applies to all children registered:</div> <div> As parent/guardian of the child(ren) registered, I hereby give my consent for my minor child(ren) to participate in Word of Life at Grace Evangelical Church and all related activities.  I understand that all reasonable safely precautions will be taken by the leaders of the activities, and that the possibility of an unforeseen hazard does exist.  I further agree not to hold Grace Evangelical Church, its leaders, employees, and volunteers liable for damages, losses, diseases, or injuries incurred by the minor(s) listed on this form.  I also give permission for photos from VBS to be used on Grace Evangelical Church's website.</div> <bR> <div> I understand that all efforts will be made to contact me in an emergency.  In the event I cannot be reached, I give permission to the attending physician to treat my minor child(ren).  I do consent to any x-ray, anesthetic, medical, surgical, or dental diagnosis or treatment that may be deemed necessary for my minor child(ren).  I understand that the doctors, dentists, and other providers attending to my child(ren) will take all reasonable safety precautions during their care.</div> <bR> <div> As parent or legal guardian, I am responsible for the health care decisions for my minor child(ren) and agree that my insurance plan is the primary plan to pay for the dental, medical, or hospital care or treatment that is given to my child(ren).  Grace Evangelical Church, Church staff and/or Vacation Bible School staff and volunteers will not be responsible for medical expenses incurred; these expenses will be the responsibility of the parent or legal guardian.</div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div>     </div> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE=" Grace Evangelical Church "><U><B><IMG SRC="0c740400.gif" border=0 width="64" height="64" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="index.htm" TARGET="_top" TITLE=" Grace Evangelical Church "><U><B>Home</B></U></A></div> <bR> </td> </tr></table></body>