Cornerstone Ministries Youth Parental Consent Form (2025-2026)

Cornerstone Ministries Youth Parental Consent Form

For the program year of September 1, 2025- August 31, 2026
Which program will your child be attending? Quest (Gr 4-6), Jr Youth (Gr 7-8), Sr Youth (Gr 9-12)
Parental Information
Name of Father/ Guardian #1

First NameLast Name
Phone Number of Father

Area CodePhone Number
Email Address of Father
example@example.com
Address of Father

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Mother/ Guardian #2

First NameLast Name
Phone Number of Mother

Area CodePhone Number
Email Address of Mother
example@example.com
Address of Mother

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Child

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Consenting Party
Name of Person/Organization
Address of Person or Organization
131 New Hope Drive, Box 380, Crystal City, MB, ROK ONO
Child's Medical Information
Food Allergies (Please Specify)
Drug Allergies (Please Specify)
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our staff/volunteers should be aware of? If yes, please explain.
Does your child bring any medication with him/her? If yes, please list.
Family Doctor
Phone Number of Clinic

Area CodePhone Number
Manitoba Health Family #
Manitoba Health Personal #
Additional Medical Insurance
Name of Company (ex Blue Cross)
Additional Medical Insurance Policy #
Effectivity Period
I/We, {nameOf4} and/or {nameOf23}, hereby declare that I am/We are the parent(s)/legal guardian of {nameOf}, who was born on the {dateOf}.

I/We do hereby consent to my child's medical care and the administration determined by a physician to be necessary for the welfare of my/our child while said child is under the care of {nameOf29} of {addressOf}. I/We undertake and agree to indemnify and hold blameless the Ministry Staff, Cornerstone Ministries Church, its Pastors and Church Elder Board from and against any loss, damage, or injury suffered by the participant as a result of being part of the activities of the Cornerstone Ministries Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when paticipating in or traveling to events of the Cornerstone Ministries Church.

This authorization shall be effective from {dateStart} until {dateEnd}.
Date Start

MonthDayYear
Date
Date End

MonthDayYear
Date
Signature of Father

Clear
Date signed

MonthDayYear
Date
Signature of Mother

Clear
Date signed

MonthDayYear
Date
Should be Empty: