Exchange Registration

Parent's First Name*

Parent's Last Name*

Mailing Address*

City*

State*

Zip Code*

Phone Number*

E-Mail Address*

Child's First Name*

Child's Last Name*

Child's Grade (2022-2023 school year)*

Child's Shirt Size*

Does this child have any allergies or special needs?*

Do you have another child to register for The Exchange?*

Yes
No

Child's First Name*

Child's Last Name*

Child's Grade (2022-2023 school year)*

Child's Shirt Size*

Does this child have any allergies or special needs?*

Do you have a third child to register for The Exchange?*

Yes
No

Child's First Name*

Child's Last Name*

Child's Grade (2022-2023 school year)*

Child's Shirt Size*

Does this child have any allergies or special needs?*

Do you have a fourth child to register for The Exchange?*

Yes
No

Child's First Name*

Child's Last Name*

Child's Grade (2022-2023 school year)*

Child's Shirt Size*

Emergency Contact Name:*

Emergency Contact Phone Number:*

The following people are allowed to pick up my child/children from The Exchange on Wednesday evenings:*

Please use first and last names. Anyone who comes to pick up your that is NOT on this list must contact The Exchange Director (Shannon Malmkar) ahead of time to make arrangements.

Curriculum costs for The Exchange are $20 per child, but scholarships are available. Would you be interested in a scholarship?*

Yes
No

Consent*

I agree to The Exchange Activity Agreement.

In connection with my child or ward's voluntary involvement in activities with The Exchange at Grant Evangelical Free Church in Grant, Nebraska, a non-profit, 501(c)3 charitable organization, I with my signature agree, for myself, my heirs, assigns, executors, and administrators to release and discharge The Exchange at Grant Evangelical Free Church in Grant, Nebraska, its officers and directors, employees, agents and volunteers from all claims, demands and actions for injuries sustained to my child or ward's person and/or property as a result of his/her involvement in such activities, whether or not resulting from negligence, and I agree to release and hold The Exchange at Grant Evangelical Free Church in Grant, Nebraska, its officers and directors, employees, agents and volunteers harmless from any cause or action, claim, or suit arising from any perceived injury. I hereby attest that my child's or ward's attendance and involvement in such activities is voluntary, that he/she is participating at his/her own risk, and that I have read the above terms and conditions of release.

I hereby give permission to my child or ward to participate in all activities in the program of The Exchange at Grant Evangelical Free Church in Grant, Nebraska, expressly and specifically acknowledging that those activities may include, but not limited to classroom work and games involving physical effort and activity. I also give The Exchange at Grant Evangelical Free Church in Grant, Nebraska, permission to seek for my child or ward medical attention in case of any emergency and to administer medication that I provide for my child. I further attest that my child or ward has no allergies or special medical needs other than those listed on the previous page. I give The Exchange and/or Grant Evangelical Free Church permission to use pictures/videos for any lawful purpose including for publicity, illustration, advertising, and Web content.

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