YOUTH Registration & Medical Waiver

• 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*
   

  (###)

  -

  ###

  -

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• Additional Phone Number
   

  (###)

  -

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  -

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

  Last Name
• Emergency Contact Phone Number*
   

  (###)

  -

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  -

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• 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 and social networks, newsletters, or promotional material. *
  Yes

  No
• I give my permission to BEMC approved workers to communicate with my child(ren) outside of ministry events (by telephone, email, text messages, other social media, etc.). This does not apply to mentoring situations which require specific parental permission. *
  Yes

  No
• 1. Youth Name*
  First Name

  Last Name
• Youth E-mail
   
• Youth Phone Number
   

  (###)

  -

  ###

  -

  ####
• Grade this September*
• Are you registering for JR Youth or SR Youth?*
  JR Youth (Grades 6-8)

  SR Youth (Grades 9-12)
• 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. Youth Name
  First Name

  Last Name
• Youth E-mail
   
• Youth Phone Number
   

  (###)

  -

  ###

  -

  ####
• Grade this September
• Are you registering for JR Youth or SR Youth?
  JR Youth (Grades 6-8)

  SR Youth (Grades 9-12)
• 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?