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SENIOR YOUTH INFORMED CONSENT & PERMISSION FORM

Events for January-June 2025

LEADERSHIP TEAM

Ben & Bella Wideman, Aron & Maria Klassen, Victoria Martin, Dianna & Ryan Fowler, Sylvia & Kyle Wideman, Nick Martin, Alejandro Ramirez

EVENTS DETAILS

More event specifics including cost, items to bring and emergency contact will be sent out at the beginning of each month via email (Quench Email Blast & Whats Up @ WBC).

Special Note:  In the event of poor weather or a venue becomes unavailable, we will plan to meet at Wallenstein Bible Chapel for an evening of gym games/board games OR cancel the event. This will be communicated via church website and email. Timing may change on events as event dates get closer. Please refer to website and email communications for the most up to date information.

Risk: Please note that the events listed below include the following risks: gym games (general risk with physical activity), outdoors, physical labour, off site events in public spaces, transportation, overnight events

Friday, January 10th - Saturday, January 11th

Sleepover Night @ Hawkesville Church (15 Martha Street, Hawkesville)

7:30 pm- 10am (Saturday)

Details: Bring a sleeping bag/pillow, a board game and your favourite snack to share with everyone on the Friday night. Girls will be sleeping in the basement and the boys will have one of the upper floors.

Emergency Contact: Nick Martin - 519-575-1591

Friday, January 17th

Skating Night @ The Zone Training (483 Conestogo Rd #2, Waterloo)

8:30-10:30 p.m.

Friday, January 24th

Guest Speaker Night @ WBC - Medeba (Summer Camp in Northern Ontario)

7:30-10:30 p.m.

Friday, January 31st - Sunday, February 2nd

Graphite Winter Retreat - SEPERATE WAIVER REQUIRED

Friday, February 7th

Gym Night @ WBC (sports, large group games)

7:30-10:30 p.m.

Friday, February 14th

Valentines Box Social @ WBC

7:30-10:30 p.m.

Friday, February 21st

Worship Night @ WBC

7:30-10:30 p.m.

Friday, February 28th

Guys & Girls Night

Guys Location: Speed Quest Go Kart Track (385 Fredrick St. B7, Kitchener ON)

Girls Location: TBD - an off-site event in a public space, more details to come

7-9 p.m.

Friday, March 7th

Grand River Rocks (264 Victoria St N, Kitchener, ON N2H 5C8) - GRR also requires their own waiver (will be made available closer to)

7:30-9 p.m.

Friday, March 14th

Games (board/card) Night @ WBC

7:30-10:30 p.m.

Friday, March 21st

Worship Night @ Woodside (200 Barnswallow Dr, Elmira, ON N3B 3K2)

7:30-10 p.m.

Friday, March 28th

Progressive Dinner @ various WBC members homes

6:15-10 p.m.

Saturday, April 5th

Annual Pancake Breakfast Fundraiser @ WBC

7-11 a.m

Friday, April 11th

Kub Cars Night with Grade 8's @ WBC

7:30-10 p.m.

Friday, April 18th - Good Friday - No Youth

Friday, April 25th

Joint Young Adult & Youth Night @ WBC - worship, games, fellowship

7:30-10:30

Friday, May 2nd

Between the Lines Sports Night @ Between the Lines Sports Campus (275 Rocher Road, Listowel) - BTL also requires their own waiver for Youth who have not been before (will be made available closer to)

7:15-9:15 p.m.

Friday, May 9th

Worship Night @ WBC

7:30-10:30 p.m.

Friday, May 16th - Monday, May 19th

Spring Retreat @ JOY Bible Camp - SEPARATE WAIVER REQUIRED

Friday, May 23rd

Church Wide Game Night @ WBC

7:30-10:30

Friday, May 30th

Seniors Night @ WBC

7-9:30 p.m.

Friday, June 6th

Campfire Night @ The Kabbes Home (7781 16 Line Arthur, ON NOG 1A0)

7:30-10:30 p.m.

Friday, June 13th

Hoedown Night with Woodside Youth

Colin & AmyBeth Brubacher's home (1263 Scotch Line Road, Elmira)

6:30-10:30 p.m.

Friday, June 20th

Baseball @ Floradale Park

7-10 p.m.

Friday, June 27th

Celebration Night @ Bert & Tammy Stevens (5718 Wellington Rd 86, Ariss, N0B 1B0)

6:30-10:30 p.m.

PURPOSES AND EXTENT

Wallenstein Bible Chapel 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 it is a requirement of our insurance company and legal counsel. If you wish Wallenstein Bible Chapel to limit the information collected, or to view your child’s information, please contact us.

Date: January 7, 2025 

First Participant's Name

First Name*

Last Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

First Participant's Signature*
Second Participant's Name

First Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Third Participant's Name

First Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Fourth Participant's Name

First Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Fifth Participant's Name

First Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Sixth Participant's Name

First Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Seventh Participant's Name

First Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Eighth Participant's Name

First Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Ninth Participant's Name

First Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Tenth Participant's Name

First Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

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

First Name*

Last Name*

Emergency Contact's Phone Number*

If you or your youth would like to receive update e-mails, please add the e-mail address (es) below:

Your child must be covered by Provincial Health Insurance or equivalent medical insurance. OHIP # (optional)

Name of Family Physician:

Physician's Phone Number:
Photo/Video Consent
I understand that by checking "Yes", I am giving permission for the reasonable use of pictures containing my child(ren) taken at Youth events for church promotion (i.e. on the WBC website, used during announcements on Sunday morning services). I acknowledge that these photographs will be stored on the WBC computer's/data bases for these purposes. If I do not consent to photos being taken and used for the above purposes, I understand my responsibility to reach out directly to Katie Kuepfer, WBC Youth Ministry Coordinator (katie@wbconline.ca) to communicate this (click "Yes", but follow up with an email). *
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*

Last Name*

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

Youth Cell: (if applicable)
Does your child have any severe or life-threatening allergies? (bee stings, food, penicillin, other drugs, etc.)*
No
Yes

If yes, explain
Is your child bringing any medication with him or her? (antibiotics, ventilator, ritalin)*
No
Yes

If yes, explain
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?*
No
Yes

If yes, please explain

Note:

·  Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wallenstein Bible Chapel, its staff, and its volunteers are hereby released from any liability.

·  In the event that your child requires special medication, x-rays or treatment, the parents / guardians will be notified immediately.

·  In case of surgical emergency, I hereby give permission to the physician selected by Wallenstein Bible Chapel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

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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