Registration & Consent (Kids)

Information received is confidential and is being gathered for the purposes of serving your Child while in the care of Bethel Pentecostal Church. Any medical information collected here serves to authorize Bethel Pentecostal Church, and its staff and volunteers, to obtain medical assistance in emergencies. This form should be completed annually by the Parent/Legal Guardian.

For the school year:*
Child's Name*
Date of Birth:*
 / 
 / 
Address:*
Legal Guardian: *
Address of Guardian, if different:
Home Phone:*
-
Work Phone:
-
MCP (Health Card):*
Family Doctor:
Family Doctor's Phone Number:
-
Does your child have any allergies?*
Allergies:
In case of an emergency, please contact:*
Does your Child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of? *
If yes, please explain:
Is your Child bringing any medication with him/her? *
If yes, please list:

The safety of your Child is our primary concern. Precautions will be taken for their well-being and
protection.

I/we, the Parents or guardians named below, authorize Pastors Andrew & Deidre or one of Bethel Pentecostal Church's Program Personnel to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.

I/we, named below, undertake and agree to indemnify and hold harmless Program Personnel, Bethel
Pentecostal Church, and its Leaders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Bethel Pentecostal Church, as well as of any medical treatment authorized by the supervising individuals representing Bethel Pentecostal Church. This consent and authorization is effective only when participating in or traveling to events sponsored by Bethel Pentecostal Church.

I have read and agree to the above statement:*
PHOTOS: I agree to grant permission for the reasonable use of pictures containing my child in any or all of the following ways: Brochures, Promotion, Website, Videotaping, Newsletters, and in-house events.*

Purposes and Extent
Bethel Pentecostal Church is collecting and retaining this personal information for the purpose of enrolling your Child in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your Child, and to inform you of program updates and upcoming opportunities at Bethel Pentecostal Church. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Bethel Pentecostal Church to limit the information collected, or to view your Child’s information, please contact us.

Parent/Guardian Options
I have read, understood and agree with above and sign it to cover all Youth Ministry activities for the program year effective as stated. A separate Informed Letter of Consent will be sent home for off-site activities and activities of elevated risk.

I have read and agree to the above statements and will sign this document on the first event my child attends.*

Want to help financially support this group?
We run this program on the donations of those who support Bethel. If you would like to help support this kids group, you can securely donate through PayPal by clicking below:

Thingamajig Kids
 C$ 
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