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Ebenezer Christian Reformed Church GEMS Registration and Consent Form

Information received is confidential and is being gathered for the purposes of serving your Child while in the care of Ebenezer CRC. This form should be completed annually by the Parent / Caregiver.

This form is for the 2025/2026 School Year

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Students Name:  *
Date of Birth  *
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Grade in school  *
Parents Name(s) *
Email(s) ***please note, all email addresses listed will be added to our parent contact list. We use email as our main form of communication to keep our GEMS Parents informed throughout the year. 

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Phone Number(s) *
Mailing Address *
Church Affiliation 
How did you hear about us?
Does your Child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of?
If yes, please explain: *
Does your Child have any allergies?
 *
Is your Child bringing any medication with her?
 *
Child's Alberta Healthcare Number
 *
Medical Consent 

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

I/we, the Parents or guardians named below, authorize Ebenezer CRC GEMS Ministry 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 GEMS Ministry Personnel, Ebenezer CRC, 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 Ebenezer CRC, as well as of any medical treatment authorized by the supervising individuals representing Ebenezer CRC. This consent and authorization is effective only when participating in or travelling to events sponsored by Ebenezer Christian Reformed Church.


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Photo And Digital Use Consent

Please sign below to grant permission for the reasonable use of pictures or video containing your child in one or more of the following ways (check all that you accept)

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Required
Purpose and Extent 

Ebenezer Christian Reformed 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 our Church.

This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Ebenezer Christian Reformed Church to limit the information collected, or to view your child’s information, please contact us.

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


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Required
I have read the above information and understand that by checking the box below I agree that:
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Required
Signature of Parent/Legal Guardian
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Date of Signature
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Club Dues:

$50 per girl or $90 per family. Dues offset the cost of study materials, badges, and craft supplies. Your help with our annual fundraiser is appreciated. Additional fees for off-site activities may be required.

Payment options are listed below, please select one:

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Required
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