Blank Waiver

Youth/Childrens Ministries Registration Form For the 2012 / 2013 Ministry Year Information received is confidential and is being
gathered for the purposes of serving your child while in the care of High River Alliance Church. Any medical information collected here serves to authorize High River Alliance Church, and its staff and volunteers, to obtain medical assistance in emergencies. Students Name:
Date of Birth (Y/M/D):
Current Grade (2012/13):
Home Phone #:
Address: Students e-Mail Address:
Postal Code:
Cell Phone #:
Alberta Health #:
Family Doctor/Phone Number:
Allergies:
Other Health Concerns (glasses, hearing aids, other aids, etc.): Parent(s) or Legal Guardian(s) Name(s): Parent(s) e-Mail Address: Parent(s) Cell Phone #:
Emergency Contact Name:
Emergency Contact Relationship:
Phone #:
Does your child have any physical, emotional, mental, behavioural concerns or limitations that our staff should be aware of? Yes No If yes, please explain: __________________________________________________________________________________________ __________________________________________________________________________________________ Is your child bringing any medication with him/her? Yes No If yes, please list: __________________________________________________________________________________________ __________________________________________________________________________________________
The safety of your child is our primary concern. Precautions will be taken for his/her wellbeing and protection. I/we, the parents or guardians named below, authorize Pastor Owen Scott or one of the High River Alliance Church Ministry Personnel to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above. I/we, named below, undertake and agree to indemnify and hold blameless Ministry Personnel, High River Alliance Church, its Pastors and Board of Elders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the High River Alliance 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 High River Alliance Church. Photos I hereby grant permission to High River Alliance Church, on behalf of my child to photograph or videotape my child; display or reproduce any of my childs work which is produced during participation in programs for non-profit, educational and/or promotional purposes. I understand the production(s)/work(s) may be shown in newsletters, during regular church events, and other church-related activities at High River Alliance Church or at HRAC-sponsored displays in the community, or used on HRAC's website. Purposes and Extent High River Alliance 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 Church. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish High River Alliance Church to limit the information collected, or to view your childs information, please contact us.
Signature Options In the case of custody agreements, please include the proper form authorizing parental contacts. 1. Long Term Option (for all Youth/Childrens Ministries): I have read, understand and agree with the above and sign it to cover all High River Alliance Church Youth/ Childrens Ministries activities for the 2012/13 ministry year. Parent/Guardian Signature: ___________________________________________________________________ Printed Name: __________________________________________________ Date: _____________________ Effective from date signed through August 31, 2013. OR If you would prefer to consent for a single specific youth event, complete the form and sign the box below only: 2. Single Event Option (for Youth Ministry only): I have read, understand and agree with the above and sign it to cover the High River Alliance Church Youth Ministries activity listed below only. Activity: ______________________________________________ Date of Activity: ____________________ Parent / Guardian Signature: __________________________________________________________________ Printed Name: __________________________________________________ Date: _____________________

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Youth/Childrens Ministries Registration Form For the 2012 / 2013 Ministry Year Information received is confidential and is being

Date of Birth (Y/M/D):

Current Grade (2012/13):

Address: Students e-Mail Address:

Family Doctor/Phone Number:

Emergency Contact Name:

Emergency Contact Relationship:

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