New Customer Registration Form

About My Student:

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Name*

First NameLast Name

Phone Number

E-mail*

example@example.com

Emergency Contact Phone Number:*

Please enter a valid phone number.

Allergies/Medications/Medical Conditions we may need to know about (particularly in case of emergency):

Parent Consent & Release

I give permission for my child to participate in all Christian Life Church kids and youth programs, including weekly activities, events, and outings, whether on or off church property.

I understand that I do not need to be notified of each individual event. I understand that church leaders and volunteers will take reasonable steps to provide a safe environment, but I also recognize that participation carries some risks. I accept those risks on behalf of my child.

I give permission for my child to be transported as needed for program activities.

In the event of illness or injury, I authorize Christian Life Church leaders or volunteers to seek medical care for my child, including treatment by a licensed physician or health care provider. I understand that the Church will attempt to contact me, as soon as practicable under the circumstances. I agree to be responsible for all related expenses.

I, the parent or guardian or authorized caregivers named above, authorize the ministry staff of Christian Life Church Inc., operating as Christian Life Church, 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 named above, undertake and agree to indemnify and hold blameless the ministry staff, Christian Life Church, its pastors and Board of Directors from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Christian Life 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 traveling to events of Christian Life Church.

I also agree to inform the church of any medical or health conditions that could affect my child’s participation.

Parent/Guardian Signature

Christian Life Church, Inc., operating as Christian Life Church, 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 our church. This information will be maintained permanently as it is a requirement of our insurance company and legal counsel. If you wish Christian Life Church to limit the information collected, or to view your child’s information, please contact us.

Photo & Media Release: I understand that Christian Life Church may take photos or videos during youth programs. These may be used in slideshows, church promotions, or social media.

Yes, I give permission for my student's image to be used.No, I do not give permission for my student's image to be used.

Parent/Guardian Info