Youth Registration 2025

Parent/Guardian Name*

First NameLast Name

Student Name #1*

First NameLast Name

Birth Date of Youth #1

MonthDayYear

Health card number of Youth #1*

Student's name #2

First NameLast Name

Birth Date #2

MonthDayYear

Health card number #2

Student's Name #3

First NameLast Name

Birth Date #3

MonthDayYear

Health card of Youth #3

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact:*

Phone Number*

Any allergies or special requests:

Do you approve of your child being photographed? Photos will be used for in house activities, PPT social media.

YESNO

I (We) the undersigned, personally in the case of a participant over the age of eighteen years, or on behalf of our child, in the case of a participant who is not yet eighteen years of age, do hereby release, remise and forever discharge Pembroke Pentecostal Tabernacle, their heirs, executors, administrators, successors and assigns, including the operator of the actual activity, including the bus driver and bus company which may transport us or our child to the said activity, from any and all actions, causes of actions, damages, claims, and demands whatsoever which we or our child ever had, or may hereafter be brought against any of the said parties or on behalf of us or our said child in respect or arising out of the aforesaid accident, any bodily or emotional injury or death arising out of our participation or the participation of our child in the above described activity.

Additional Comments

PARENTAL CONSENT FORM
I, the undersigned First Name Last Name am the parent or legal guardian of the child/children named above. As parent or legal guardian I give consent for my child/children named above to attend PPT YOUTH at Pembroke Pentecostal Tabernacle, Pembroke Ontario, and any special PPT YOUTH events which may take place off the church property. As a parent or legal guardian, I hereby voluntarily release, forever discharge the community, the corporation, its officers, directors, employees, volunteer and agents of Pembroke Pentecostal Tabernacle from any and all claims, demands, or causes of action, which are connected with my child's participation in the programs or the use of the equipment and facilities. I (We) The understand, in the event medial treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give permission to a licensed medical practitioner to provide the necessary care, including anesthesia, for my child's / children's well being. By signing this form on Date I confirm that I have fully informed myself of the contents of this Parental Consent and Release Form by reading it before I signed it. I warrant that I possess all the rights, powers, and privileges of a parent or legal guardian necessary to execute this document with binding legal effect. Signature
First Name Last Name

Youth Registration 2025-2026