Youth Ministry Registration and Consent Form
Information received is confidential and is being gathered for the purposes of serving your Child while in the care of Rockcliffe Pentecostal Church.  Any medical information collected here serves to authorize Rockcliffe Pentecostal Church and its Staff & Volunteers, to obtain medical assistance in emergencies.This form should be completed annually by the Parent / Care Giver.
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                                                       A Place For Family to Gather Together
Name of Person Filling Out Form (Parent or Guardian) *
Today's Date *
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Student Name *
Date of Birth *
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Address *
Main Phone Number *
Email
Name of School & Grade
Health Card # *
Family Doctor Name & Phone Number *
In Case of Emergency, Contact *
Does your child have any allergies? (please list below)
Does your child have any physical, emotional, mental, behavior concerns or limitations that staff should be aware of? (please list below)
Is your Child bringing any medication with him/her?  (please list below)
Has Your Child Been Immunized? (We do not restrict access to children who have not been immunized, however, we request that we be notified if they have not been immunized. This information will be used to protect all children who have and who have not been immunized.)           *
Required
Communication - (A policy is in effect that communication is to be used solely for the conveyance of information. Please check  yes or now, to grant permission for Youth Ministry staff & volunteers to communicate with your child via telephone, email, social media and text: *
Required
Photos - Please check yes or no, to grant permission for the reasonable use of pictures containing your child in brochures, promotional material, Rockcliffe's website, social media (Facebook, Instagram, and YouTube), Rockcliffe newsletters, and videos.                                                 *
Required
I/we, the Parents or guardians named above, authorize Jeff Adams or one of Rockcliffe Pentecostal Church's Youth Ministry Personnel 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.

I/we, named above, undertake and agree to indemnify and hold harmless Program Personnel, Rockcliffe Pentecostal 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 Rockcliffe Pentecostal Church, as well as of any medical treatment authorized by the supervising individuals representing Rockcliffe Pentecostal Church.  This consent and authorization is effective only when participating in or traveling to events sponsored by Rockcliffe Pentecostal Church.
Parent / Guardian Options
I have read, understood and agree with the above and sign it to cover all Youth Ministry Activities for the program year effective stated below. A separate informed Letter of Consent will be sent home for all off-site activities and activities of elevated risk. If you have any questions or concerns please call RPC office at 519-376-1284 x 221 or Pastor Phil at 519-373-3560.

By clicking "send" you hereby give permission for your child to attend and participate in RPC's Youth Program under the guidance of our Youth leaders and volunteers.

This permission form is effective: September 15, 2023 to October 1, 2024

This form is in accordance with the Rockcliffe Pentecostal Church Protection Policy approved July 19, 2023.

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