Kid's Ministry Registration and Consent Form for the school year 2023/2024
Information received is confidential and is being gathered for the purposes of serving your child while in the care of East Side Church of God. Any medical information collected here serves to authorize East Side Church of God, and its staff and volunteers, to obtain medical assistance in emergencies.
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Grade/Age for 2023/2024
*
Not applicable (0-2 years)
Preschool (age 3 - 5)
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Parent(s)/Guardian(s) Names (please list both parents if applicable)
*
First Names
Last Name
Mailing Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Allergies
Does your child have any physical, mental, emotional or behavioral concerns or limitations that staff should be aware of?
*
Yes
No
If yes, please explain
Is your child bringing any medication with him/her?
*
Yes
No
If yes, please list
The safety of your child is our primary concern. Precautions will be taken for their well-being and protection. I/we, the parents or guardians named below, authorize Sara Wallace 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, named below, undertake and agree to indemnify and hold harmless Program Personnel, East Side Church of God, 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 East Side Church of God, as well as of any medical treatment authorized by the supervising individuals representing East Side Church of God. This consent and authorization is effective only when participating in or traveling to events sponsored by East Side Church of God.
Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
*
Brochures/Promotional Material
Website
Video recording
Church
Newsletters
Prayer Cards
None of the above
Purposes and Extent
East Side Church of God is collecting and retaining this personal information for the purpose of enrolling your child in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child and to inform you of program updates and upcoming opportunities at East Side Church of God. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish East Side Church of God to limit the information collected, or to view your child's information, please contact us.
Would you be interested in serving in Kid's Ministry at East Side?
*
Yes
No
I'd like more information
I have read, understood and agree with the above.
*
Yes
Signature
*
Parent Name
*
Submit
Should be Empty: