CHILDREN'S MINISTRY Registration & Medical Waiver

• Are you registering for FaithBuilders, Kids Club or VBS?*
  FaithBuilders (Sunday AM)

  Kids' Club (Weeknights)

  VBS (Summer Program)
• Parent/Guardian Name*
  First Name

  Last Name
• Address*
  Street Address*

  Address Line 2

  City*

  Province / State / Region*

  Postal Code / Zip

  Antigua and BarbudaBahamasBarbadosBelizeCanadaCosta RicaCubaDominicaDominican RepublicEl SalvadorGrenadaGuatemalaHaitiHondurasJamaicaMexicoNicaraguaPanamaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesTrinidad and TobagoUnited StatesArgentinaBoliviaBrazilChileColumbiaEcuadorGuyanaParaguayPeruSurinameUruguayVenezuelaAlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandItalyLatviaLiechtensteinLithuaniaLuxembourgMacedoniaMaltaMoldovaMonacoMontenegroNetherlandsNorwayPolandPortugalRomaniaSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandUkraineUnited KingdomVatican CityAfghanistanBahrainBangladeshBhutanBrunei DarussalamMyanmarCambodiaChinaEast TimorIndiaIndonesiaIranIraqIsraelJapanJordanKazakhstanNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLebanonMalaysiaMaldivesMongoliaNepalOmanPakistanPhilippinesQatarRussiaSaudi ArabiaSingaporeSri LankaSyriaTaiwanTajikistanThailandTurkeyTurkmenistanUnited Arab EmiratesUzbekistanVietnamYemenAustraliaFijiKiribatiMarshall IslandsMicronesiaNauruNew ZealandPalauPapua New GuineaSamoaSolomon IslandsTongaTuvaluVanuatuAlgeriaAngolaBeninBotswanaBurkina FasoBurundiCameroonCape VerdeCentral African RepublicChadComorosCongoDjiboutiEgyptEquatorial GuineaEritreaEthiopiaGabonGambiaGhanaGuineaGuinea-BissauCôte d\'IvoireKenyaLesothoLiberiaLibyaMadagascarMalawiMaliMauritaniaMauritiusMoroccoMozambiqueNamibiaNigerNigeriaRwandaSao Tome and PrincipeSenegalSeychellesSierra LeoneSomaliaSouth AfricaSudanSwazilandTanzaniaTogoTunisiaUgandaZambiaZimbabwe

  Country*
• Your E-mail*
   
• Phone Number*
   

  (###)

  -

  ###

  -

  ####
• Additional Phone Number
   

  (###)

  -

  ###

  -

  ####
• Emergency Contact Name (other than parent)*
  First Name

  Last Name
• Emergency Contact Phone Number*
   

  (###)

  -

  ###

  -

  ####
• I give my permission to BEMC to use my child’s/children’s name(s) and/or photo(s) on material posted within the church.*
  Yes

  No
• I give my permission to BEMC to use my child’s/children’s name(s) and/or photo(s) on material posted on the church website, newsletters, or promotional material outside of the church.*
  Yes

  No
• I give my permission to BEMC to contact me via email with other church event details and promo materials.*
  Yes

  No
• 1. Child Name*
  First Name

  Last Name
• Grade this September*
• Date of Birth*
  MM

  /

  DD

  /

  YYYY
• Health Card Number (with Version Code)*
• Allergies?*
• Does your child carry an Epipen or Inhaler?*
  Yes

  No
• If Yes, please explain. Note: If yes, Appendix 11 should be completed in addition to this form.
• Are there any physical, emotional, mental or behavioural concerns or limitations that our staff should be aware of?
• 2. Child Name
  First Name

  Last Name
• Grade this September
• Date of Birth
  MM

  /

  DD

  /

  YYYY
• Health Card Number (with Version Code)
• Allergies?
• Does your child carry an Epipen or Inhaler?
  Yes

  No
• If Yes, please explain. Note: If yes, Appendix 11 should be completed in addition to this form.
• Are there any physical, emotional, mental or behavioural concerns or limitations that our staff should be aware of?
• 3. Child Name
  First Name

  Last Name
• Grade this September
• Date of Birth
  MM

  /

  DD

  /

  YYYY
• Health Card Number (with Version Code)
• Allergies?
• Does your child carry an Epipen or Inhaler?
  Yes

  No
• If Yes, please explain. Note: If yes, Appendix 11 should be completed in addition to this form.
• Are there any physical, emotional, mental or behavioural concerns or limitations that our staff should be aware of?