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JR YOUTH INFORMED CONSENT & PERMISSION FORM

FALL RETREAT WEEKEND

October 18th-19th, 2024


EVENT DETAILS

Location: Conestoga Bible Camp (6791 Leslie Lane, Moorefield ON, N0G 2K0)

Cost: $60 per child

Drop off @ 6:30 p.m. AT CBC on Friday, October 18th

Pick up @ 4:30 p.m. AT CBC on Saturday, October 19th

THIS FORM + $60 DUE October 13th, 2024. Cheques can be made to WBC (Jr Youth Retreat in the note), and cash must be exact. Submit directly to Katie Kuepfer on Wednesday, or to the Info Centre on Sunday.

Possible activities: outdoor games (volleyball, camp wide games) indoor activities, worship & teaching time (with guest speaker Adam Hockley), small group time. Full packing list available via email.

Chaperones: Josh Ramirez, Bryce Kuepfer, Kirby Bauman, Molly Wagler, Kendrick Kuepfer, Kierra Martin, Katie Kuepfer

Emergency Contact: Katie Kuepfer (226-989-5999) or Conestoga Bible Camp (519-638-2440)

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: November 16, 2024 



First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's 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*
Second Participant's Date of Birth*
Second Participant's 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*
Third Participant's Date of Birth*
Third Participant's 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*
Fourth Participant's Date of Birth*
Fourth Participant's 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*
Fifth Participant's Date of Birth*
Fifth Participant's 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*
Sixth Participant's Date of Birth*
Sixth Participant's 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*
Seventh Participant's Date of Birth*
Seventh Participant's 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*
Eighth Participant's Date of Birth*
Eighth Participant's 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*
Ninth Participant's Date of Birth*
Ninth Participant's 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*
Tenth Participant's Date of Birth*
Tenth Participant's 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*

Your child must be covered by Provincial Health Insurance or equivalent medical insurance. OHIP # (optional)

Name of Family Physician:

Physician's Phone Number:
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*
Parent or Guardian's 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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