Children Registration Form • Covenant Christian Community Church

First Name *

Last Name *

School Grade *

Date of Birth *

Email Address *

Health Card Number *

Allergies *

Known physical, emotional, mental or behavioural concerns or limitations (if none, simply write none) *

Emergency Contact Name *

Emergency Contact Number *

Emergency Contact Relationship to Student (ie. Parent, Grandparent, Guardian, etc) *

I/we, the parents or guardians named above, authorize Brent Jefkins 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 (we will contact the parent/guardian in any emergency as soon as possible) *

I/we Agree

I/we named above, undertake and agree to indemnify and hold blameless the Pastor, the Ministry Staff, Covenant church, its Pastors and Church Board from and against any loss, damage or injury suffered by the supervising individuals representing the church *

I/we Agree

We consent to photos to be taken of the student named above and to be used on our social media platforms *

Signature of Parent/Guardian (type name) *