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AUTHORIZATION & MEDICAL CONSENT FORM AWANA – Ministry Year of 2019/2020

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.

Note: If your child has an epi-pen, a photo of your child needs to be submitted to the church office.

Signature of Consent:
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 above, authorize the Port Perry Baptist Church Ministry Personnel to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.

I/we, named above, 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 is effective only when participating in or traveling to events of the Port Perry Baptist Church.

Ministry Activities

I have read, understood and agree with the above and sign it to cover all ministry activities. Note: Ministry activities include but are not limited to:

  • campfires
  • gym games
  • baking
  • crafts
  • jumping castle
  • costume nights

Parent Signature:


Date: September 20, 2019

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

Third Participant's Name

First Name*

Middle Name

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

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

Fourth Participant's Name

First Name*

Middle Name

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

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

Fifth Participant's Name

First Name*

Middle Name

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

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

Sixth Participant's Name

First Name*

Middle Name

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

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

Seventh Participant's Name

First Name*

Middle Name

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

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

Eighth Participant's Name

First Name*

Middle Name

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

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

Ninth Participant's Name

First Name*

Middle Name

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

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

Tenth Participant's Name

First Name*

Middle Name

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

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

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

Emergency Contact's 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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Grade in September *

Health Card Number *

Family Doctor *

Phone Number *

Allergies *

Restricted Foods
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our ministry personnel should be aware of?*
No
Yes

If yes, please explain.
Is your child bringing any medication with him/her?*
No
Yes

If yes, please list:

Home Church (if any)

If you DO NOT WANT your child to participate in any of the above, please list below.


Activity

Effective from date signed through

Photos

Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways:
Brochures/Promotional material
Church
Website
Newsletters

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.

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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