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SENIOR YOUTH INFORMED CONSENT & PERMISSION FORM

Events for January-June 2026

LEADERSHIP TEAM

Ben & Bella Wideman, Aron & Maria Klassen, Victoria Martin, Sylvia & Kyle Wideman, Nick Martin, Alejandro Ramirez, Jackson Martin, Makayla Brubacher

EVENTS DETAILS

More event specifics including cost, items to bring and emergency contact will be sent out at the beginning of each month via email (Quench Email Blast & What's Up at WBC), and posted weekly to WBC WhatsApp group.

Special Note:  In the event of poor weather or a venue becomes unavailable, we will plan to meet at Wallenstein Bible Chapel for an evening of gym games/board games OR cancel the event. This will be communicated via church website, email and WhatsApp.

Risk: Please note that the events listed below include the following risks: gym games (general risk with physical activity), outdoors, physical labour, off site events in public spaces, transportation

Friday, Jan 9th

Worship @ WBC

7:30-10:30 p.m.

Friday, January 16th

Skating (Brian Gingrich - Rd #2 Drayton 7433 8th line N0G 1P0)

7:30-9:30 p.m.

Friday, January 23rd

Dodgeball Night (@ WBC in Gym)

7:30-10:30 p.m.

Friday, January 30th

Graphite Weekend Retreat (Graphite Bible Camp)

We will have a separate waiver for this retreat weekend.

Friday, February 6th

Sledding (Anything but a sled) Location TBD

7:30-10:30 p.m.

Friday, February 13th

Valentines Box Social (@ WBC) 

7:30-10:30 p.m.

Friday, February 20th

Skyzone (Kitchener Skyzone)

7:00 - 9:00 p.m.

Friday, February 27th

Worship Night With Young Adults (@ WBC Downstairs)

7:30-10:30 p.m.

Friday, March 6th

Guys / Girls Night

(Guys Night: Kingpin Bowling 425 Bingemans Centre Dr, Kitchener, ON N2B 3X7) -Guys pay for themselves

(Girls Night: Pottery Painting at Play With Clay 42 Wyndham Street North, Guelph, ON N1H4E6) -Girls pay for themselves

7-9pm (GUYS)   Girls: TBD

Friday, March 13th

Progressive Supper

Meet at WBC

6-10pm

Saturday, March 21st

Pancake Breakfast (@ WBC Kitchen and Gym)

8am-12pm

Friday, March 27th

Event with Jr. Youth (@ WBC Upstairs)

Time: TBD

Friday, April 10th

Mall Hunt (@ Conestoga Mall)

7-10pm

Friday, April 17th

Worship Night - with Woodside invited (@ WBC Downstairs)

7:30 - 10:30 p.m.

Saturday, April 25th

Serving Event Work Day

9am-12pm

Friday, May 1st

Parent Night (@ WBC Downstairs)

7:30 - 10:30 p.m.

Friday, May 8th

Between the Lines (275 Rocher Rd, Listowel, ON N4W 0B2)

7:15 - 9:30 p.m.

Friday, May 15th

Joy Bible Camp Retreat (@ Joy Bible Camp)

We will have a separate waiver for the retreat.

Friday, May 22nd

Photo Scavenger Hunt

More details: TBD

Friday, May 29th

Seniors Night Hymn Sing (@ WBC Sanctuary)

7-10p,m.

Friday, June 5th

Grand River Rocks

Time: TBD

Friday, June 12th

Hoedown (Woodside hosting, details: TBD)

Friday, June 19th

Baseball (Floradale Park & Brad and Lynne Martin's 2204 Floradale Rd)

7:30 - 10:30 p.m.

Friday, June 26th

Celebration Night (Ryan and Kaylin's)

Time: TBD

PURPOSES AND EXTENT

Wallenstein Bible Chapel 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 indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Wallenstein Bible Chapel to limit the information collected, or to view your child’s information, please contact us.

Date: December 27, 2025 

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
If you or your youth would like to receive update e-mails, please add the e-mail address (es) below:
Your child must be covered by Provincial Health Insurance or equivalent medical insurance. OHIP # (optional)
Name of Family Physician:
Physician's Phone Number:
Photo/Video Consent
I understand that by checking "Yes", I am giving permission for the reasonable use of pictures containing my child(ren) taken at Youth events for church promotion (i.e. on the WBC website, used during announcements on Sunday morning services). I acknowledge that these photographs will be stored on the WBC computer's/data bases for these purposes. If I do not consent to photos being taken and used for the above purposes, I understand my responsibility to reach out directly to Katie Kuepfer, WBC Youth Ministry Coordinator (katie@wbconline.ca) to communicate this (click "Yes", but follow up with an email). *
Yes
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes
If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes
If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes
If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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