Youth Ministry Student Registration & Waiver

Youth Ministry Student Registration & Waiver

Registration and waiver for Middle School (Grades 6-8) and High School (Grades 9-12) Youth Ministry programs at North Kildonan Mennonite Brethren Church, 1315 Gateway Road, Winnipeg, MB, Canada. Information received is confidential and is being gathered for the purposes of serving your Child while in the care of the church. Any medical information collected here serves to authorize the church and its Ministry Personnel to obtain medical assistance in emergencies. This form should be completed annually by the parent/legal guardian for each attending student.
Student Information
Student Name *

First Name Last Name
Grade 2022/23 *
School 2022/23
Birthdate *

Year Month Day
Male/Female *

Male Female
Medical # *
6 digit
Personal Health # *
9 digit
Allergies or Health Concerns

Parent/Guardian Information
Parent/Guardian 1 *

First Name Last Name
Parent 1 Cell Phone Number

Area Code Phone Number
Relationship to Child Registered *
Parent/Guardian 2

First Name Last Name
Parent 2 Cell Phone Number

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Family Phone Number *

Area Code Phone Number
Parent/Family Email *
Our primary method of communication with parents will be through regular email updates.
If there is any important family information you think we may need to know about, please include here:
Family Church Affiliation (if any)
Church Name
Emergency Contact Information

Please list an emergency contact other than yourself or your spouse.
Emergency Contact Name (other than yourself or spouse) *

First Name Last Name
Phone Number *

Area Code Phone Number

Permission/Waiver
At North Kildonan MB Church (NKMB) we highly value the safety of your child. To that end we have trained our staff and volunteers in our Safe Place Policy. All youth workers have been vetted before assuming leadership roles. All reasonable precautions will be taken to ensure the safety of your child(ren) during our program(s).

By signing this form you acknowledge that you have read and agree to the following:

I/we consent to my child participating in ministry activities at NKMB Church. These activities include but are not limited to gym activities, games, Bible studies and small group sessions. Offsite activities include events like bowling or laser tag. Small group events may be held in the church building, in a Program Personnel's home, the park, or other public locations.

I/we, authorize one of the church’s Youth Program Personnel 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.

I/we, undertake and agree to indemnify and hold harmless Program Personnel, the church, and its leaders, from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the church, as well as of any medical treatment authorized by the supervising individuals representing organization. This consent and authorization is effective only when participating in or traveling to events sponsored by the NKMB church.

I/we consent to NKMB Church to record my son/daughter's participation in any programs or events associated with NKMB Youth. Further, I hereby transfer and assign to NKMB Church the exclusive right to use and to authorize others to use said images, video, and audio recordings for promotional and educational use or resource sale in the future. I/we understand that my son/daughter's image may be used, but their name or personal information will never be shared publicly without additional, separate consent.

I/we give consent for my child to be driven by ministry personnel at times during offsite events within the parameters of the Safe Place Policy. I/we understand that transportation to and from a youth event is my responsibility.

I/we consent to Program Personnel communicating with my child through social media/text/email provided contact information is supplied or contact is initiated by myself or my child. All electronic interactions are to be kept on record.

I/we consent that the parent email address provided will be added to our NKMB Youth mailing list to be used solely for the dissemination of information.

I/we understand that my child may be asked to discontinue participating should he/she disregard our code of conduct. A copy of the code of conduct is available on request.
Signature *

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