Registration and Consent Form

(To be completed for Youth under 19)

2012-2013
Even though each activity will be carefully planned and adequately supervised by mature adults, unforeseen
events can occur. By signing this form, the parent, or guardian, agrees and accepts all risks and hazards
inherent in church-related activities.
Name: __________________________________________________ Birth Date: ______________________
Address: ____________________________________________________Postal Code: __________________
Phone: ________________________________________ Alternate: _________________________________
Grade (September 2012):_________ Email:____________________________________________________
Home Church (if have one): _________________________________________________________________
BC Care Card #: ____________________________________________
Private Insurance Coverage: ___________________________________
Any medical or allergy information we should know about: ________________________________________
Any Special medication your child is using: _________________________________________
Person to be notified in emergency (relationship): ____________________________ Phone # ____________

Consent
I consent to my son/daughters attendance and participation in the activities of the youth ministries of
Chilliwack Baptist Church
In the event of a medical emergency, I understand that an effort will be made to reach me. However, I
give the leaders of the church youth ministries the authority to act on my behalf and to authorize treatment
for my child if necessary during the event that the parent/guardian is unable to provide such consent. I
also understand that I am liable and agree to pay for all costs and expenses incurred.
I release the church (paid and non-paid staff, members, and volunteers) and event-related companies and
staff against all losses, claims, suits, and demands, or any liabilities whatsoever arising from injury or
death to the child or other persons involved.
I understand that Chilliwack Baptist Church will collect and securely retain the above information for
record-keeping purposes.
I give permission for my childs picture and/or name to appear, on occasion, on promotional or invitational
materials or website affiliated solely with Chilliwack Baptist Church.

Parent or Guardian: ________________________________________________________

Signature: ________________________________________________________ Date: ______________
46336 First Avenue
Chilliwack, B.C.
V2P 1W7

Telephone: 604-792-3988
Fax: 604-792-9053
e-mail:theoffice@chilliwackbaptist.com