Loading...

JR YOUTH INFORMED CONSENT & PERMISSION FORM

FALL RETREAT WEEKEND

October 20th-21st, 2023


EVENT DETAILS

Location: Conestoga Bible Camp (6791 Leslie Lane, Moorefield ON, N0G 2K0)

Cost: $60

Drop off @ 6:30 p.m. AT CBC on Friday, October 20th

Pick up @ 4:30 p.m. at CBC on Saturday, October 21st

THIS FORM + $60 DUE October 14th. Cheques can be made to WBC (Jr Youth Retreat in the note), and cash must be exact. Submit directly to Katie Kuepfer on Wednesday, or to the Info Centre on Sunday.

Possible activities: outdoor games (volleyball, camp wide games) indoor activities, worship & teaching time, small group time. Full packing list available via email.

Chaperones: Josh Ramirez, Bryce Kuepfer, Kirby Bauman, Molly Wagler, Katie Kuepfer

Emergency Contact: Katie Kuepfer (226-989-5999) or Conestoga Bible Camp (519-638-2440)

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: June 16, 2025 



First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
Participant's Date of Birth*
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*
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 Jr 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*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!