Fraser Lands Kidz Ministry Registration Form
Registration form for 2016-2017
What program(s) do you want to register your child in?
Please check ALL that applies to your child.
Required
Last name of your child
Your answer
First name of your child
Your answer
What is the name your child responds to?
Your answer
Male or Female?
What is your child's birthdate?
MM
/
DD
/
YYYY
What grade is your child in?
Address
Street Address
Your answer
City
Your answer
Postal Code
Your answer
Home Phone Number
Your answer
Email Address
Your answer
Cell Phone Number for Emergency Contact
Your answer
Name of Parent(s)/Guardian(s)
Your answer
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.
Your answer
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
Your answer
Child's Physician
Your answer
Child's Physician's Phone Number
Your answer
Care Card No.
Your answer
Medical Conditions or Allergies
Your answer
Is your child bringing any medication with him/her?
If yes, please list the medication:
Your answer
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our staff should be aware of?
If yes, please explain:
Your answer
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.
Your answer
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.
Your answer
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
Your answer
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