Bethel Kids Wednesday Night Ministry REGISTRATION FORM
Name of Child (First and Last) *
Your answer
Gender *
Date of Birth *
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Grade *
Your answer
School *
Your answer
Home Address *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Mother's Name *
Your answer
Father's Name *
Your answer
Email *
Your answer
Emergency Contact Name *
Your answer
Relation to Child *
Your answer
Emergency Contact Home Phone *
Your answer
Emergency Contact Cell Phone *
Your answer
My Child’s picture, without name, may be used for Event promo purposes (Bethel’s website/social media) *
Does you child have any life threatening allergies *
If yes please explain
Your answer
Is your child bringing any medication with him or her? (ie.: Epipen, Inhaler) *
Required
If yes please explain
Your answer
Does your child have any physical, emotional, mental or behavioral concerns/limitations that staff should be aware of? *
If yes please explain *
Your answer
Your child must be covered by Provincial Health Insurance or equivalent medical insurance:
Provincial Health Number *
Your answer
Name of Family Physician *
Your answer
Family Physician Phone Number *
Your answer
Precautions are taken for the safety and health of your child. In the event of accident or sickness, we need your authorizationin regards to the following:I, the Parent or Guardian named below, authorize the Pastors of Bethel Pentecostal Church or one of the Bethel KidsPersonnel 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.
Parent's Signature (this electronic signature will serve as your signature) *
Your answer
Date *
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I, the Parent or Guardian named below, give permission for my child to participate in Bethel Kids Wednesday night ministry.I undertake and agree to release from liability, indemnify and hold harmless Bethel Kids Wed Night Personnel, BethelPentecostal Church, its staff, and its volunteers from and against any loss, damage or injury suffered by participant as a result of being part of the activities of Bethel Kids Ministry as well as of any medical treatment authorized by the supervising individuals representing Bethel Pentecostal Church.
Parent's Signature (this electronic signature will serve as your signature) *
Your answer
Date *
MM
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DD
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YYYY
Children’s Ministries - Bethel Pentecostal Church, 500 Viewmount Drive, Nepean, ON K2E 7P2Bethel Kids Wednesday Night Ministry INFORMED LETTER OF CONSENT FOR TRANSPORTATION to and from: Bethel Pentecostal Church (500 Viewmount Dr., Ottawa)and the following locations: Dynes – Rideauview (Eiffel)/Rideauview Terrrace (Debra)for Wednesday Night Kids Program
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