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BAC YOUTH REGISTRATION AND CONSENT FORM

2021 – 2022

Information received is confidential and is being gathered for the purpose of serving our youth while in the care of Beaverlodge Alliance Church. The safety of your child is our primary concern. Precautions will be taken for their wellbeing and protection.

 

Informed Letter of Consent for Transportation

I give permission for my child(ren) to be transported in a motor vehicle driven by a youth leader. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or other adult volunteers. All youth leaders that are driving are required to follow all rules of the road, and will be required to sign off on a drivers contract with the Beaverlodge Alliance Church. I understand that participating in the identified event is not a requirement for participation in Beaverlodge Alliance Church activities.

I have read, understand, and discussed with my child(ren) that:
They will be traveling in a motor vehicle driven by an adult and accompanied by a second adult, and they are to wear their safety-belt while traveling;
They are expected to respect each other, the vehicles they ride in, and the people they travel with during the trip;
They are to remain in their seats and not be disruptive to the driver of the vehicle; and
Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects.

I recognize that by participating in these activities, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

 

Informed Letter of Consent for Medical Treatment

I/we, the parents or guardians named above, authorize Nate Perry (Pastor of Student Ministries) or BAC 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(s) named above. We also give permission for information in this document to be provided to medial personnel if required.

I/we, named above, undertake and agree to indemnify and hold blameless BAC, the ministry staff/volunteers, it’s Pastors and Board of Elders from and against any loss, danger or injury suffered by the participant as a result of being a part of the activities of BAC, as well as of any medical treatment authorized by the supervising individuals representing BAC. This consent and authorization is effective only when participating in or traveling to events of BAC.

 

Consent for Photos

I understand that my student may be photographed or recorded on video during the course of youth ministry events. I consent to Beaverlodge Alliance Church’s use of my student’s image in either print, electronic or video form in promotion material, the church website or church run social media (Instagram & Facebook).

Today's Date: May 28, 2022 

First Participant's Name

First Name*

Middle Name

Last Name*

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
Third Participant's Name

First Name*

Middle Name

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
Fourth Participant's Name

First Name*

Middle Name

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
Fifth Participant's Name

First Name*

Middle Name

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
Sixth Participant's Name

First Name*

Middle Name

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
Seventh Participant's Name

First Name*

Middle Name

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
Eighth Participant's Name

First Name*

Middle Name

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
Ninth Participant's Name

First Name*

Middle Name

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
Tenth Participant's Name

First Name*

Middle Name

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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
In case of parents living in a separate residence

In case of parents living in a separate residence, please indicate if there are specific pick-up instructions for your youth and inform us of any changes.
PREFERRED MODE OF COMMUNICATION

Please mark preferences for communication below. In doing so, you give permission for Youth staff/volunteers to contact yourself or your child via the following methods.

Child younger than 13yrs. will be contacted only through parents listed above


Please select preferred contact mode:*

Email or text

Add me to Facebook or Instagram. My name is

Child 13 - 18 yrs. can be contacted 

Please select preferred contact mode

Email or Text

Add me to Facebook or Instagram. My name is
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

Heath Card Number *

Grade *
Does your child have any allergies or physical, emotional behavioural concerns or limitations that our staff/volunteers should be aware of?*
No
Yes

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

If yes, please list
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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