Fraser Lands Kidz Ministry Registration Form
Registration form for 2019-2020
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What program(s) do you want to register your child in? *
Please check ALL programs that your child will attend.
Required
Last name of your child *
First name of your child *
What is the name your child responds to? *
Male or Female? *
What is your child's birthdate? *
MM
/
DD
/
YYYY
What grade is your child in? *
Address *
Street Address
City *
Postal Code *
Home Phone Number *
Email Address *
Cell Phone Number for Emergency Contact *
Name of Parent(s)/Guardian(s) *
Photo & Video Consent
During events and activities hosted by Fraser Lands, such as Sunday School, Nursery, Kidz Kamp, VBS, Awana, etc., we take photos and/or videos that include children, alumni, and adults. We use these photos and videos in our website, promotions, bulletin boards, and sometimes in information sheets and brochures. (Note: Fraser Lands will not publish names or other information that might make children individually identifiable.)
 I hereby give Fraser Lands Church, its employees and those acting with its authorization, the permission to use and/or publish photographs/videos of my child, ______________ in promotional materials listed above. *
Please fill in your CHILD'S name.
Health Information
Information received is confidential and is being gathered for the purposes of serving your child while in the care of Fraser Lands Church. Any medical information collected here serves to authorize Fraser Lands Church, and its staff and volunteers, to obtain medical assistance in emergencies.
Child's Name *
Child's Physician *
Child's Physician's Phone Number *
Care Card No. *
Medical Conditions or Allergies *
Is your child bringing any medication with him/her? *
If yes, please list the medication:
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our staff should be aware of? *
If yes, please explain:
Authorization and Medical Consent
The safety of your child is our primary concern. Precautions will be taken for his/her well-being and protection. It is our policy to notify a parent/guardian when a child is ill or needs medical attention. Occasionally, we are unable to contact the parent/guardian and/or we need to get immediate help for the child. Therefore, your authorization and medical consent is required for us to deal with such occasions.
I hereby authorize one of the Fraser Lands Church Ministry Staff or Volunteer to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment, or procedures for my child, ___________, in the event of any medical emergency. *
Please fill in your CHILD'S name.
I undertake and agree to indemnify the Ministry Staff and Volunteers of Fraser Lands Church, its' Pastors and Board of Elders from, and against, any loss, damage, or injury suffered by my child, _________________, as a result of being part of the activities of the Fraser Lands Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or travelling to and/or from events of the Fraser Lands Church. *
Please fill in your CHILD'S name.
Parent/Guardian Acknowledgement
AWANA (6:50pm-9:00pm)
9:15am Nursery or Sunday School (9:10am-10:40am)
11:00am Nursery or Sunday School or Kidz Church (10:55am-12:30pm)
I,_______________, understand and acknowledge that when my child participates in the children's programs listed above, they are under supervision only during the applicable time periods stated above, and hereby agree and acknowledge that all the information above is true. *
Please fill in Parent/Guardian's name (*fill in your fulll name and/or provide a signature)
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