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PPBC Soccer Program 2024 Consent Form 

Please note:

Children must be 3yrs old before May 1, 2024
Payment of $40 per child must be paid via cash or cheque on the first night of soccer
This year, children will be put into age groups based on their age at registration 

Age Groups:

Ages 3&4, 5&6, 7&8, 9-12

The safety of your child is our primary concern. Precautions will be taken for their well-being and protection. Information received is confidential and is being gathered for the purposes of serving your child while in the care of Port Perry Baptist Church. Any medical information collected here serves to authorize Port Perry Baptist Church, and its staff and volunteers, to obtain medical assistance in emergencies.

In the case of custody agreements, please include the proper form authorizing parental contacts.

(1) I/we, the parents or guardians, authorize the Port Perry Baptist Church Ministry 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 above.

(2) I/we, undertake and agree to indemnify and hold blameless the Ministry Personnel, Port Perry Baptist Church, its Pastors, and Board of Elders from and against any loss, damage, or injury suffered by the participant as a result of being part of the activities of the Port Perry Baptist Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization are effective only when participating in or traveling to events of the Port Perry Baptist Church.

May 2, 2024 

I Agree

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Allergies (please list):

please list any allergies
Will your child be bringing an epi-pen?
Please select*
No
Yes
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?
Please select*
No
Yes

If yes, please explain:
Is your child bringing any medication (other than an Epi Pen) with him/her?
Please Select*
No
Yes

If yes, please list
T-shirt Size:
Please select your child's shirt size*
Request to play on the same team as... (please limit to 1 player and note that it is not guaranteed)

1 Player (first & last name)
SNACK: During many of our programs food is offered to the children/youth. This can include candy, gum, chocolate, baked goods (home-made and/or store-bought), freezies or chips. If for any reason you DO NOT wish for your child to consume any food products while in our program, please indicate below:
Please select one*
Please list any restricted foods:

Please list here
Special Instructions in Regards to Medical Treatment

Please describe if any
Home Chuch (if any):

Your answer here
How did you hear about PPBC Soccer Program?

Your answer here
Would you like to know about other children's programs at Port Perry Baptist Church?
Please select a response*
No
Yes
Photos: I grant permission for the reasonable use of pictures containing my child in any or all of the following ways:
Check all that apply
Brochures/promotional material
Church
Website
Newsletters
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:*
Purposes and Extent: Port Perry Baptist Church is collecting and retaining this personal information for the purpose of enrolling your child in our programs, 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 Port Perry Baptist Church to limit the information collected, or to view your child's information, please contact us. I have read, understood and agree with the above.
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact'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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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