This registration form MUST be filled out be a Parent or Legal Guardian of listed students.

Tip: A new form must be completed for each school year.

STUDENT INFORMATION

MEDICAL INFORMATION (& Other Special Concerns)

Tip: Please list any medications that your child or student KEEPS WITH THEM. (ie: epipen, insulin, inhaler, etc.)

PLEASE NOTE: If any of your child(ren) require, or may require, the use of any medication or emergency treatment, such as an EpiPen, Inhaler or other such medications, please provide Southwood Church staff/volunteers with written permission to administer medications, as well as, written instructions on how to administer them. These instructions will be given to your childrens teachers, and supervising staff.

Tip: List any of the above that will help us keep your child or youth engaged and safe in any programs or activities at Southwood United Church.

CONTACT INFORMATION

Tip: Best Contact Number

Optional Contact Information for Students 13-17 Years of Age

PARENT/GUARDIAN INFORMATION

Tip: Name or Names of Parents or Guardians

Tip: Best Contact Number

Tip: Best Contact Email for Parent Guardian Contact

Tip: Please let us know if there are any guardianship or custody agreements in place that affect contacts or pick-up arrangements or restrictions, including names of authorized or restricted contact individuals.

In Case of Emergency Contact:

CONSENT & RELEASE

Communication with Junior & Senior High Students

A policy is in effect that direct communication with students is to be used solely for the dissemination of information.

Please select below which means of communication you grant permission for Children/Youth Program Ministry Personnel, Staff and/or Volunteers to communicate with your students in Grades 7-12. (No direct communication is made with students in Grades 6 or under).

Media

From time to time Ministry Personnel, Staff and/or Program Leaders may wish to take photos during activities. The following policies apply to all photos:

  • No photos are posted DURING events.
  • Photos NEVER have children or youth identified by name.
  • Photos are NEVER posted without express permission unless the photo is taken during an event considered to be a 'public performance'.
  • If a group photo includes a child or youth from whom photo permissions have not been granted, any identifying features of that student will be obscured.

Please choose below which (if any) permissions you grant for reasonable use of pictures containing your child.

Purposes & Extent

I/we, the parents or guardians named above, authorize one of Southwood United Church Ministry Personnel, Staff and/or Volunteers to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above, in the case of emergency.

I/we, named below, undertake and agree to indemnify and hold harmless Ministry Personnel, Staff and/or Volunteers, Southwood United Church, and its Leaders from and against any loss, damage, or injury suffered by the participant as a result of being part of the activities of Southwood United Church, as well as of any medical treatment authorized by the supervising individuals representing Southwood United Church. This consent and authorization is effective only when participating in or traveling to events sponsored by Southwood United Church.

Southwood United Church 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 organization. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Southwood United Church to limit the information collected, or to view your childs information, please contact us.

Southwood United Church will never sell or otherwise distribute your information.

Parent/Guardian Options

I have read, understood, and agree with above, and sign it to cover all Children/Youth Program activities for the program year effective as stated above.

A separate Letter of Informed Consent will be sent home for off-site activities and activities of elevated risk.

Tip: Enter the name of Parent or Legal Guardian Completing Registration & Date Completed