CHILDREN'S MINISTRY REGISTRATION AND CONSENT FORM: Information received is confidential and is being gathered for the purposes of serving your Child while in the care of Church of the Open Bible. Any medical information collected here serves to authorize Church of the Open Bible, and its staff and volunteers, to obtain medical assistance in emergencies.
*
Please check school year and you will be prompted to fill in the year manually. (You may use this form to register more than one child)
Activity or program
*
Choose all that apply
In the case of custody agreements, please include the proper form authorizing the Parental contacts. Student's Name
*
First Name
Last Name
Student's Name
Use this field if registering more than one Child
First Name
Last Name
Student's Name
Use this field if registering more than one Child
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Date of Birth
Use this field if registering more than one child (in the order named above)
MM
DD
YYYY
Date of Birth
Use this field if registering more than one child (in the order named above)
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
*
(###)
###
####
Parent's Work Number
(###)
###
####
Health Card Number
*
Family Doctor
*
First Name
Last Name
Phone Number for Doctor
(###)
###
####
Allergies
*
Yes
No
In case of emergency, contact:
*
First Name
Last Name
Emergency Contact Phone Number
*
(###)
###
####
Does your Child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of?
*
Yes
No
Is your Child bringing any medication with him/her?
*
Yes
No
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 in this form, authorize {program leader} or one of the Church of the Open Bible Personnel 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 in this form.
*
Yes
No
I/we, named below, undertake and agree to indemnify and hold harmless Program Personnel, Church of the Open Bible, 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 Church of the Open Bible, as well as of any medical treatment authorized by the supervising individuals representing Church of the Open Bible. This consent and authorization is effective only when participating in or traveling to events sponsored by Church of the Open Bible.
*
Yes
No
PHOTOS I hereby grant Church of the Open Bible permission to use the likeness of my child in a photograph or video in any and all of its publications, including social media without payment or any other consideration. I hereby authorize such use as publishing the photographs on posters, pamphlets, social media, websites, etc. but does NOT include permission to publish my child's name, address of other personal information except with prior written consent from me. I hereby hold harmless and release and forever discharge Church of the Open Bible from all claims, demands and causes of action which I, council members, representatives, executors, administrators, or any other persons acting on behalf of Church of the Open Bible have or may have reason of this authorizaiton.
*
Choose all that apply
PURPOSES AND EXTENT Church of the Open Bible 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 opportunities at our organization. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Church of the Open Bible to limit the information collected, or to view your Child's information, please contact us.
*
Parent's Name
First Name
Last Name
Date Signed
*
MM
DD
YYYY
