Annual Jr/Sr Youth Registration • Emmanuel Evangelical Missionary Church

Parent/Guardian's Name *

First Name *

Last Name *

Date of Birth *

Student's school grade as of this September *

Home Address

Child's Health Card Number *

Email Address *

Mobile Number *

What school does your student attend?

Does this student have any allergies, medical conditions or other concerns that would benefit us to know? (we will keep this confidential) *

PERMISSIONS

In the event of where your student is injured or requires immediate medical treatment we will attempt to contact you ASAP. If contact isn't made do you permit us to take preliminary steps of treatment?(First Aid, CPR, Hospital treatment) *

Do we have your permission to publish pictures and videos of your student for our social media and church media presentations? *

EEMC 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 ur insurance company and legal counsel. If you wish EEMC to limit the information collected, or to view your children's information, please contact us.

CONSENT
I/we the parents or guardians, authorize the Ministry Leader, a trained volunteer or one of the EEMC Ministry Staff 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, if EEMC Ministry Staff have been unable to contact me/us as parents or guardians.

I/we undertake and agree to indemnify and hold blameless the Ministry Leader, the Ministry Staff, EEMC, its Pastors and Governing Church Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the EEMC, as well as of any medical treatment authorized by the supervising individuals representing the church.

By clicking below I am affirming that I have read, understood and agree with the above statements *