Information received is confidential and is being gathered for the purposes of serving your child while in the care of Rocky Mountain Alliance Church. Any medical information collected here serves to authorize Rocky Mountain Alliance Church, and its staff and volunteers, to obtain medical assistance in emergencies. This form must be completed annually by the Parent/Guardian.
Youth’s Name
Date of Birth - YYYY-MM-DD
Address
Home Phone Number
Email
Parent/Guardian Phone Number
Health Card Number
Family Doctor
Doctor's Phone Number
Allergies and Reactions
Emergency Contact Name
Emergency Contact Phone Number
Does your Child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of? —Please choose an option—YesNo
If yes, please explain:
Is your Child bringing any medication with him/her? —Please choose an option—YesNo
If yes, please list:
The safety of your Child is our primary concern. Precautions will be taken for their well-being and protection.
I/we, the Parents or guardians named below, authorize one of Rocky Mountain Alliance Program Personnel to sign a consent for medical assessment, treatment or procedures for the participant named above.
I/we, named below, undertake and agree to indemnify and hold harmless Rocky Mountain Alliance 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 Rocky Mountain Alliance Church, as well as any medical treatment authorized by the supervising individuals representing Rocky Mountain Alliance Church. This consent and authorization is effective only when participating in or travelling to events sponsored by Rocky Mountain Alliance Church.
Please check below to grant permission for the reasonable use of pictures containing your Child in any of the following ways: Brochures/Promotional materialOrganizationWebsiteNewslettersVideotaping
Rocky Mountain Alliance Church is collecting and retaining this personal information for the purpose of enrolling your child in our programs, nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities at our organization. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Rocky Mountain Alliance Church to limit the information collected, or to view your child’s information, please contact us (403-845-2610).
I confirm that I am the Parent/Guardian of the Child and I have read, understood and agree with above and sign it to cover all Youth Program activities for the program year effective as stated below. A separate Informed Letter of Consent will be sent home for off-site activities and activities of elevated risk.
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