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BEMC Youth Program for those in Grades 6-12
For more information contact the youth leaders at
breslauemc.youth@gmail.com
WANT TO JOIN? HAVE A PARENT OR GUARDIAN FILL OUT THE FORM BELOW!
YOUTH Registration & Medical Waiver
Breslau Evangelical Missionary Church
102 Woolwich Street S., Breslau ON N0B 1M0 (519) 648-2712 www.bemc.ca
The youth program at Breslau Evangelical Missionary Church is a ministry for students in grade 6-12. It involves Bible studies and social events as well as occasional regional events. All of our youth leaders are approved workers and follow the Plan to Protect adopted by the Deacons’ board. It is our desire to minister to the youth of our community in a fun, safe, and meaningful manner.
Purposes and Extent
Breslau Evangelical Missionary Church is collecting and retaining this personal information for the purpose of enrolling your child(ren) in our programs, to assign them to the appropriate classes, to develop and nurture ongoing relationships with you and your child(ren), 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 Breslau Evangelical Missionary Church to limit the information collected, or to view your child’s/children’s information, please contact us.
The information on this form will be used for all field trips & special events in the current school year and following summer. However, each time we have an overnight trip, we will ask you to fill out a separate form for the specific trip. Thank you!
*Your youth should not carry any medication other than an EpiPen or inhaler to any non-overnight event.
Waiver – Please Read Carefully
I/we, the parents or guardians named below, authorize the ministry staff of Breslau Evangelical Missionary Church to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for participant(s) named above.
I/we, named below, undertake and agree to indemnify and hold blameless the Ministry Staff, Breslau Evangelical Missionary Church, its Pastors and Board of Deacons from and against any loss, damage or injury suffered by the participant(s) as a result of being part of the activities of the Breslau Evangelical Missionary Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to events of the Breslau Evangelical Missionary Church.
By submitting this form I, the parent or guardian named below, acknowledge that I have read, understood, and agree with the information for the program year.
Parent/Guardian Name
*
First Name
Last Name
Address
*
Street Address
*
Address Line 2
City
*
Province / State / Region
*
Postal Code / Zip
Antigua and Barbuda
Bahamas
Barbados
Belize
Canada
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Columbia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Côte d\'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
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 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?