GEMS Registration 2021-2022

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Email *

Girl’s First Name: *

Girl’s Last Name: *

Birth Date: *

YYYY

Grade: *

Do you attend church? If so, where?

What school do you attend? *

Parent(s)/Guardian(s) name(s): *

Address: *

Address, City, Postal Code

Phone Number: *

Emergency Contact (Name & Phone Number) *

Health Card#/Medical Release *

I, the parent or legal guardian of child listed above, a minor, by submitting this health card number, hereby authorize and give permission to the physician or medical practitioner, selected by Bethany Christian Reformed Church to hospitalize, secure proper treatment including but not limited to the prescription of medications, diagnostic studies, and any other medical procedure for my child as deemed necessary by the physician under the circumstances. It is understood that this authorization is given in advance of any specific medical treatment being needed, and is given to provide authority to the physician to render that care which in exercise of his or her best judgment is advisable.

Allergies/Medical Conditions *

Media Consent *

I agree that photographs and/or videos may be taken of my child at Bethany Christian Reformed Church programs and events, and may be used in the promotion of Bethany Christian Reformed Church. They may be published or used for any application in newspapers, videos, posters, slide presentations, FaceBook, YouTube, other social media and networking sites or otherwise displayed to the public—either in whole or in part by Bethany Christian Reformed Church.

Transportation Consent for Off- Site Outings *

I authorize the transportation of my child by a volunteer or staff person of Bethany Christian Reformed Church, in a church member's vehicle, to activities I will be previously informed of and for which I will have given my express permission.

Parents must physically sign in and sign out their child each week on the designated sign in and sign out sheets. I acknowledge that I must sign my child in and out in the designated area each week.

Covid 19 Screening *

Parents must screen their child each week before GEMS to verify their child doesn't exhibit any symptoms of COVID-19 or they have not been in contact with someone who has tested positive . They also must wear a mask for the duration of the GEMS program within the building. I agree to pre-screen my child each week prior to GEMS to ensure they do not shows any signs of Covid-19.

Yes

Registration Fee *

The Registration Fee is $50/girl. Payment can be brought on the Kick Off Evening. Please choose your method of payment:

Cash

Cheque (made out to Bethany CRC)

E-Transfer to info@bethanycrc.ca (please make the password “Bethany” and your Child's name as the message)

Send me a copy of my responses.

Submit

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