a program sponsored by First United Methodist Church of Los Angeles Registration Form – Winter 2011-2012 714 West Olympic Blvd, Suite 920, Los Angeles, CA 90015

1021 S. Hope St., Los Angeles, CA 90015 [email protected] • 213- 308-6701 Participant’s name: _________________________________ Birthday: ____________________________ Participant’s phone number (if any): ____________________ Email: ______________________________ Food allergies, medical conditions or other special needs: _______________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Name of Mother/Father/Legal Guardian _____________________________________________________ Address: _____________________________________________________________________________ City/State/Zip Code _____________________________________________________________________ Home phone ________________________________ Cell phone _________________________________ Email: _______________________________________________________________________________ Best way to reach you: __________________________________________________________________

In case of emergency contact: _____________________________________________________ Relation to child ____________________________ Phone _____________________________ Alternate phone 1 ___________________________ Alternate phone 2 ____________________ 2nd emergency contact: __________________________________________________________ Relation to child ____________________________ Phone _____________________________ Alternate phone 1 ___________________________ Alternate phone 2 ____________________ Page 1 of 4

First UMC – Additional Permissions Policy for children arriving and leaving the program Thank you for trusting us with your child in our program! In order to make sure that children arrive and leave the program safely, we ask you to please help us enforce the following policy: Arriving to the program: Upon arrival, participants sign their name, date and time in the sign-in book. Since students often arrive alone, we assume they have your permission to attend the program for the day. Leaving the program: Parents must initial one option, and sign below to indicate how each child/children will leave the program. ____Option 1: My child, _________________________ has my permission to sign out and leave the program and walk home alone or with other children or youth. (First UMC will see that children who live in Hope Place leave through the elevator or Hope Place lobby doors.) ____Option 2: My child, _________________________ does not have my permission to sign out and leave the program alone or with other children. I or one of the people authorized below will pick up my child. Only the people listed below have permission to pick up my child from the program: ________________________________________________________________________ Participants may meet at 1021 S Hope Street, Los Angeles, CA 90015 or at 714 West Olympic Blvd, Suite 920, Los Angeles, CA 90015 I have read and completed the above supplemental permission: __________________________ Parent or Guardian of child named above

Photo Release Form Use of Photos: The staff at First UMC take pictures and videos of participating children and teens throughout the year to illustrate, for you and them, the many activities in which they are engaged. Some photos are used in program activities, such as collages, and others are displayed in the First UMC space. They are also posted on Kid City’s secure facebook and myspace pages for parents, kids, teens, and supporters of Kid City and First UMC to view but not download. (Anyone who wants to join the Kid City South Park groups on facebook and myspace must submit a request and be approved by Kid City staff. Only people known to staff are permitted to join.) We understand the sensitive nature of social networking sites and take every measure to assure that our pages are not public. Some photos will be used in slide shows and other publicity materials, primarily used to present to funders and potential funders. In some cases, we would like to make these photos available to the general public online, such as on the First UMC, Religion and Culture in Los Angeles, Kid City and Urban Foundation websites, so that potential funders and other supporters may see the exciting things we are doing. Permission: I grant permission to First UMC to electronically record my child’s image during class activities, which may appear in the forms described above. I have noted any exception in writing, below. Child’s Name ____________________________ Date: _________________________________ Parent’s Name ___________________________ Parent’s Signature _______________________ Please list any specific exceptions here: PARENT PERMISSION FORM FOR FIELD TRIPS AND ACTIVITIES Page 2 of 4

PARENT PERMISSION FORM FOR FIELD TRIPS AND ACTIVITIES With First United Methodist Church First UMC’s winter program will include local field trips as follows, to churches, temples, mosques, synagogues and sacred spaces. I/We,

the parents/guardians of: _________________________________________ , _________________________________________

understand the nature of the trips being planned to the following places during the following days and times: The Islamic Center of Southern California, 434 S Vermont Ave, Los Angeles Friday, December 30, 11:00 am – 4:00pm Occupy the Light at Pershing Square, 532 S Olive St, Los Angeles Wednesday, December 21, 4:30 – 8:00pm Temple Israel of Hollywood, 7300 Hollywood Blvd, Los Angeles, CA Wednesday, January 4, 2012; Meet at 9:00am to travel by van and/or car San Gabriel Mission, San Gabriel, CA Wednesday, Dec 28, 2011; Meet at 10:00am to travel by van and/or car 3rd Church of Christ, Scientist, 7th and Hope, Downtown LA Thursday, Dec 29, 2011

Additional field trips may be scheduled to the following sites. Specific dates and times are TBD. Hsi Lai Temple, 3456 Glenmark Dr, Hacienda Heights Wilshire Boulevard Temple, 3663 Wilshire Blvd, Los Angeles Cathedral of Our Lady of the Angels, 555 W Temple St, Los Angeles Higashi Honganji Buddhist Temple, 505 E 3rd St, Los Angeles Saint Sophia Greek Orthodox Cathedral, 1324 S Normandie Ave, Los Angeles All field trips will take place from December 19, 2011 to January 6, 2012, Monday through Friday, between the hours of 9am and 5pm, unless otherwise noted. We understand that transportation will be by foot, car, van and bus and we are in accord with the purposes of and procedures governing the trip. We hereby grant permission for our son/daughter to participate. We understand that adequate and appropriate supervision will be provided. We recognize, however, that unanticipated situations and problems can arise on any trip, which situations or problems are not reasonably within the control of the supervising staff (including volunteers). We further agree to release and hold harmless First United Methodist Church, their agents, officers, employees, and volunteers, from any and all liability, claims, suits, demands, judgments, costs, interest and expense (including attorneys' fees and costs) arising from such activities, including any accident or injury to the student and the costs of medical services. In the event of an injury requiring medical attention, I hereby grant permission to the supervising staff (including volunteers) to attend to my son/daughter. If the injury warrants further medical attention, I expect every effort will be made to contact me to receive my specific authorization before action is taken. If efforts to contact me are unsuccessful, I grant permission for necessary medical treatment to be given. In addition, I hereby give my permission to the supervising staff (including volunteers) to

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take my child to the physician, dentist, or to the nearest hospital if an accident or serious illness occurs on the trip and I cannot be located. In the event that a student must return independently for reasons of health, accident, failure to conform to rules established by the staff member(s) in charge, etc., we agree to accept full responsibility for and to pay for the cost of medical care, transportation and other incidental expenses. This permission slip also serves as a contract that the child and parent(s) understand and agree to the guidelines from staff as to appropriate behavior during the field trip. If the student requires medication I understand that I am obligated to ensure that the medication is given by me; the staff of First United Methodist Church are not under obligation to ensure that medicine is provided or taken by the child while on the field trip. ________________________________________________________________________________ Parent or Guardian (signed) Home Phone ___________________Work Phone ___________________Cell ______________ Best way to reach you __________________________________________________________ Home Address_________________________________________________________________________ In case of emergency we will first attempt to contact the parent or guardian. In case the parent or guardian is not reachable, please provide other people we can contact in case of emergency, in the order in which you would like us to contact them: 1st Emergency Contact Name: ____________________________________________________________ Full Address: _________________________________________________________________________ Home Phone: _________________________________________________________________________ Cell: ________________________________________________________________________________ Relationship to child: ___________________________________________________________________ 2nd Emergency Contact Name: ____________________________________________________________ Full Address: _________________________________________________________________________ Home Phone: _________________________________________________________________________ Cell: ________________________________________________________________________________ Relationship to child: ___________________________________________________________________

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