Family Registration Form - St. Andrew's Presbyterian Church 2016-2017
Family Name *
Your answer
Child 1 (Name, Birth date, Grade, Health Card, Personal Email)
Your answer
Child 2 (Name, Birth date, Grade, Health Card, Personal Email)
Your answer
Child 3 (Name, Birth date, Grade, Health Card, Personal Email)
Your answer
Child 4 (Name, Birth date, Grade, Health Card, Personal Email)
Your answer
Address *
Your answer
Family Physician and Phone Number *
Your answer
Phone Number(s) *
Your answer
Email Address(es)
Your answer
Preferred Method of Contact (Email, Text Message, Facebook, Phone/Voicemail) *
Your answer
Allergies, Special Needs, Sensitivities or Notes
Your answer
All reasonable precautions for the safety and health of the participant will be taken. He/she will be properly supervised in activities. In the event of accident or sickness, St. Andrew’s Presbyterian Church, its staff and volunteers are released from any liability.In the event of injury requiring medical attention, I authorize treatment for the participant and understand that reasonable attempts will be made to contact me, (or a residential staff) should such a situation occur. In the event that travel or activities take place outside this province, I understand that any medical costs incurred involving the participant is my responsibility.The participant must be covered by provincial health insurance or equivalent medical coverage.If the trip is outside of province, please give insurance provider and policy number. *
Photo Release: I grant St. Andrew’s Presbyterian Church in Kitchener, the right to take photographs of me and my family in connection with church organized services and events. I authorize St. Andrew’s Presbyterian Church in Kitchener, its assigns and transferees to copyright, use and publish the same in print and/or electronically. *
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