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CONSENT FORM - YOUTH

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.

For the Ministry year 2019/2020

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

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.

PLEASE NOTE: Ministry activities may include but are not limited to:

  • indoor gym games such as dodgeball, basketball, volleyball etc.;
  • outdoor games such as soccer, baseball, man-hunt, etc.;
  • special events which may include dunk tanks, inflatable games, slip and slides, etc.

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.

Today's Date: February 22, 2020

First Participant's Name

First Name*

Last Name*

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

Health Card Number

Family Doctor

Phone Number

Please list any allergies
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 medications, an epi-pen or asthma puffer with him/her?*
No
Yes

If yes, please list

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


    Activity Excluded

    Note: All off-site trips and retreats will have a separate consent form. 

      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
      Youth Facebook Page
      Newsletters
      Youth Instagram Account

      Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
      Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
      Telephone (home / work / cell)
      Social Media Networks (Facebook, Instagram, etc.)
      Email
      Text
      Newsletter
      First Participant's Signature*
      Second Participant's Name

      First Name*

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

      Health Card Number

      Family Doctor

      Phone Number

      Please list any allergies
      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 medications, an epi-pen or asthma puffer with him/her?*
      No
      Yes

      If yes, please list

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


        Activity Excluded

        Note: All off-site trips and retreats will have a separate consent form. 

          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
          Youth Facebook Page
          Newsletters
          Youth Instagram Account

          Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
          Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
          Telephone (home / work / cell)
          Social Media Networks (Facebook, Instagram, etc.)
          Email
          Text
          Newsletter
          Third Participant's Name

          First Name*

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

          Health Card Number

          Family Doctor

          Phone Number

          Please list any allergies
          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 medications, an epi-pen or asthma puffer with him/her?*
          No
          Yes

          If yes, please list

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


            Activity Excluded

            Note: All off-site trips and retreats will have a separate consent form. 

              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
              Youth Facebook Page
              Newsletters
              Youth Instagram Account

              Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
              Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
              Telephone (home / work / cell)
              Social Media Networks (Facebook, Instagram, etc.)
              Email
              Text
              Newsletter
              Fourth Participant's Name

              First Name*

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

              Health Card Number

              Family Doctor

              Phone Number

              Please list any allergies
              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 medications, an epi-pen or asthma puffer with him/her?*
              No
              Yes

              If yes, please list

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


                Activity Excluded

                Note: All off-site trips and retreats will have a separate consent form. 

                  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
                  Youth Facebook Page
                  Newsletters
                  Youth Instagram Account

                  Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
                  Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
                  Telephone (home / work / cell)
                  Social Media Networks (Facebook, Instagram, etc.)
                  Email
                  Text
                  Newsletter
                  Fifth Participant's Name

                  First Name*

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

                  Health Card Number

                  Family Doctor

                  Phone Number

                  Please list any allergies
                  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 medications, an epi-pen or asthma puffer with him/her?*
                  No
                  Yes

                  If yes, please list

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


                    Activity Excluded

                    Note: All off-site trips and retreats will have a separate consent form. 

                      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
                      Youth Facebook Page
                      Newsletters
                      Youth Instagram Account

                      Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
                      Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
                      Telephone (home / work / cell)
                      Social Media Networks (Facebook, Instagram, etc.)
                      Email
                      Text
                      Newsletter
                      Sixth Participant's Name

                      First Name*

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

                      Health Card Number

                      Family Doctor

                      Phone Number

                      Please list any allergies
                      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 medications, an epi-pen or asthma puffer with him/her?*
                      No
                      Yes

                      If yes, please list

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


                        Activity Excluded

                        Note: All off-site trips and retreats will have a separate consent form. 

                          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
                          Youth Facebook Page
                          Newsletters
                          Youth Instagram Account

                          Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
                          Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
                          Telephone (home / work / cell)
                          Social Media Networks (Facebook, Instagram, etc.)
                          Email
                          Text
                          Newsletter
                          Seventh Participant's Name

                          First Name*

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

                          Health Card Number

                          Family Doctor

                          Phone Number

                          Please list any allergies
                          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 medications, an epi-pen or asthma puffer with him/her?*
                          No
                          Yes

                          If yes, please list

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


                            Activity Excluded

                            Note: All off-site trips and retreats will have a separate consent form. 

                              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
                              Youth Facebook Page
                              Newsletters
                              Youth Instagram Account

                              Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
                              Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
                              Telephone (home / work / cell)
                              Social Media Networks (Facebook, Instagram, etc.)
                              Email
                              Text
                              Newsletter
                              Eighth Participant's Name

                              First Name*

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

                              Health Card Number

                              Family Doctor

                              Phone Number

                              Please list any allergies
                              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 medications, an epi-pen or asthma puffer with him/her?*
                              No
                              Yes

                              If yes, please list

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


                                Activity Excluded

                                Note: All off-site trips and retreats will have a separate consent form. 

                                  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
                                  Youth Facebook Page
                                  Newsletters
                                  Youth Instagram Account

                                  Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
                                  Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
                                  Telephone (home / work / cell)
                                  Social Media Networks (Facebook, Instagram, etc.)
                                  Email
                                  Text
                                  Newsletter
                                  Ninth Participant's Name

                                  First Name*

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

                                  Health Card Number

                                  Family Doctor

                                  Phone Number

                                  Please list any allergies
                                  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 medications, an epi-pen or asthma puffer with him/her?*
                                  No
                                  Yes

                                  If yes, please list

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


                                    Activity Excluded

                                    Note: All off-site trips and retreats will have a separate consent form. 

                                      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
                                      Youth Facebook Page
                                      Newsletters
                                      Youth Instagram Account

                                      Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
                                      Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
                                      Telephone (home / work / cell)
                                      Social Media Networks (Facebook, Instagram, etc.)
                                      Email
                                      Text
                                      Newsletter
                                      Tenth Participant's Name

                                      First Name*

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

                                      Health Card Number

                                      Family Doctor

                                      Phone Number

                                      Please list any allergies
                                      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 medications, an epi-pen or asthma puffer with him/her?*
                                      No
                                      Yes

                                      If yes, please list

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


                                        Activity Excluded

                                        Note: All off-site trips and retreats will have a separate consent form. 

                                          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
                                          Youth Facebook Page
                                          Newsletters
                                          Youth Instagram Account

                                          Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
                                          Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
                                          Telephone (home / work / cell)
                                          Social Media Networks (Facebook, Instagram, etc.)
                                          Email
                                          Text
                                          Newsletter
                                          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*

                                          Last Name*

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

                                          Health Card Number

                                          Family Doctor

                                          Phone Number

                                          Please list any allergies
                                          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 medications, an epi-pen or asthma puffer with him/her?*
                                          No
                                          Yes

                                          If yes, please list

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


                                            Activity Excluded

                                            Note: All off-site trips and retreats will have a separate consent form. 

                                              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
                                              Youth Facebook Page
                                              Newsletters
                                              Youth Instagram Account

                                              Food - During many of our programs food is offered to the youth. This can include candy, gum, chocolate, baked goods (home-made and/or store bought). Please list any restricted foods
                                              Communication A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Youth Ministry Personnel (staff and volunteers) to communicate with your child via telephone, email, social media and text.
                                              Telephone (home / work / cell)
                                              Social Media Networks (Facebook, Instagram, etc.)
                                              Email
                                              Text
                                              Newsletter
                                              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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