FBC Youth
Registration Form
Registration
Information received is confidential and is being gathered for the purposes of serving your Child while in the care of Fellowship Baptist Church Collingwood. Any medical information collected here serves to authorize Fellowship Baptist Church Collingwood, and its staff and volunteers, to obtain medical assistance in emergencies.
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PARENT / GUARDIAN INFO
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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YOUTH'S CONTACT INFO
How many children will be attending FBC Youth?
*
Please Select
1
2
3
1st Youth's Info
Name
*
First Name
Last Name
Health Card
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
2nd Youth's Info
Name
*
First Name
Last Name
Health Card
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
3rd Youth's Info
Name
*
First Name
Last Name
Health card
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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YOUTH'S MEDICAL NEEDS
Do any of these youths have any severe allergies? (bee stings, food, etc.)
*
Yes
No
Please explain and indicate if an EpiPen is require
Are any of these students bringing any medication with them? (inhaler, Ritalin, etc.)
*
Yes
No
Please explain and indicate if your child cand self administer or if they require assistance
Do any of these students have any physical, emotional, mental, or behavioral concerns or limitations that our staff should be aware of?
*
Yes
No
Please explain
Emergency Contact - another adult who can be contacted in the event of an emergency and the parent/guardian can not be reached.
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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CONSENT & ACKNOWLEDGMENT
I consent to allowing youth leaders to drive my students to events off the property of FBC Collingwood.
*
Yes
No
FBC Privacy Policy
Signature
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