Ministry *

Parent or Guardian Name *

Parent Phone Number *

Alternate Phone Number *

Street Address *

City *

Province *

Postal Code *

Youth Name *

Youth Date of Birth *

Youth Gender *

Youth Allergies/Medical Conditions

Dietary restrictions *

Family Doctor *

Family Doctor Phone Number

Youth Health Card Number *

Emergency Contact Name *

Emergency Contact Number *

Will be Brought By

Will be Picked Up By

I Would Like to Help With (if any)

I Can Help on These Days

I understand that the programs involve the children participating in sports, crafts and games. These sports, crafts and games may be played indoors or outdoors. I understand that the children will be under the direction and supervision of one or more adult leaders, approved of by Cheltenham Baptist Church. I hereby waive any claim against Cheltenham Baptist Church, and its approved leaders for any accident, injury or illness that may occur while my child is participating in the Youth Group/ Vacation Bible Camp/ Sunday School/ Dragonflies/ Fireflies programs of Cheltenham Baptist Church. In the event of an Emergency, I understand every effort will be made to contact me. In the event that I cannot be reached, I hereby give my permission to the physician selected by the adult leader in charge to secure treatment for my child that is deemed necessary by the attending physician. I have noted my child?s relevant medical condition (s) and allergies, if any. *I have read and accept the above terms: *

Upon submission you will be sent a link for payment through our givings page or I understand that I will have to pay $$ upon arrival *