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Welcome to Kennedy Road Student Ministries! Information received is confidential and is being gathered for the purposes of serving your child while in the care of Kennedy Road Tabernacle. Any medical information collected here serves to authorize Kennedy Road Tabernacle, it's staff and volunteers, to obtain medical assistance in emergenices.

I/we, the parents or guardians maintain that the information contained in this form including emergency contact information, completed for the 2022/2023 school year remains entirely correct for the 2022/2023 school year for student ministries programs and will not hold Kennedy Road Tabernacle responsible for any information that has been withheld or not updated. If I need to change any information on my child's registration form, I will complete a new form entirely.

I/we, the parents or guardians named above, authorize Kennedy Road Tabernacle staff/volunteers 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.

I/we, named above, undertake and agree to indemnify and hold blameless the Kennedy Road Tabernacle staff/volunteers, its Pastors and Board of Directors from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Kennedy Road Tabernacle, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is only for activities at Kennedy Road Tabernacle. You will be notified with a separate Informed Letter of Consent for all events that pose a higher risk, involve transportation or, events that will be held off-site.

In the unlikely event of an emergency requiring a building evacuation, I WILL NOT attempt to retrieve my child from the ministry area, as this will slow down the evacuation process. My child will be evacuated in accordance to the Emergency Response protocols and I will be able to meet my child in the designated safety zone.

I have read, understood and agree with the above and sign it to cover all Student Ministry activities for the program year effective as stated below.

Purposes and Extent

Kennedy Road Tabernacle 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 as it is a requirement of our insurance company and legal counsel. If you wish Kennedy Road Tabernacle to limit the information collected, or to view your child's information, please contact us

Adapted from Plan to Protect® posted with permission 2019

First Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
First Student(s) Date of Birth*
First Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
First Student(s) Signature*
Second Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
Second Student(s) Date of Birth*
Second Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
Third Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
Third Student(s) Date of Birth*
Third Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
Fourth Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Student(s) Date of Birth*
Fourth Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
Fifth Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Student(s) Date of Birth*
Fifth Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
Sixth Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Student(s) Date of Birth*
Sixth Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
Seventh Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Student(s) Date of Birth*
Seventh Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
Eighth Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Student(s) Date of Birth*
Eighth Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
Ninth Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Student(s) Date of Birth*
Ninth Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
Tenth Student(s) Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Student(s) Date of Birth*
Tenth Student(s) Information

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
Student(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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
In the event that we are unable to contact you (parent/guardians) who would you like us to contact?

Name *

Relationship to child

Phone Number *
Photo/Video Permission
Kennedy Road Tabernacle Photo Consent
I authorize the use my child's photo in online or print format for Internal Promotional Purposes.
I authorize the use my child's photo in online or print format for External Promotional Purposes.
I DO NOT authorize the use of my child's photo.
Consent for online groups.
I give my child permission to take part in online services or small groups.*
No
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*

Middle Name

Last Name*

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

Health Card Number: *

Doctor's Name & Phone Number *

Please list any allergies we should be aware of:
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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