Recovering Hearts for Youth and Kids

Parent/Guardian

Full Name

This address will receive a confirmation email

Phone Number

Are both parents/guardians aware that the child will be attending this program?

Yes No

Other Parent/Guardian Information

Full Name

Phone Number

Email Address

Child 1:

Child's Full Name

Date of Birth

Does the child have a sibling attending this program?

Yes No

Would it be beneficial for siblings to be placed in the same group? (We will do our best to accommodate requests; however, placement will depend on on group sizes and availability.)

Yes No N/A

Does your child have any physical, emotional, mental, behavioural or any medical concerns that our volunteers need to be made aware of? Please specify & explain.

Child 2:

Child's Name (First and Last)

Date of Birth

School Name

Does the child have a sibling attending this program? Yes No

Would it be beneficial for siblings to be placed in the same group? (We will do our best to accommodate requests; however, placement will depend on on group sizes and availability.) Yes No N/A

Does your child have any physical, emotional, mental, behavioural or any medical concerns that our volunteers need to be made aware of? Please specify & explain.

Child 3:

Full Name

Date of Birth

School Name

Does the child have a sibling attending this program? Yes No

Would it be beneficial for siblings to be placed in the same group? (We will do our best to accommodate requests; however, placement will depend on on group sizes and availability.) Yes No N/A

Does your child have any physical, emotional, mental, behavioural or any medical concerns that our volunteers need to be made aware of? Please specify & explain.

Child 4:

Full Name

Date of Birth

School Name

Does the child have a sibling attending this program? Yes No

Would it be beneficial for siblings to be placed in the same group? (We will do our best to accommodate requests; however, placement will depend on on group sizes and availability.) Yes No N/A

Does your child have any physical, emotional, mental, behavioural or any medical concerns that our volunteers need to be made aware of? Please specify & explain.

Parent/Guardian Permissions

I, the parent or guardian named in this application, authorize the ministry staff of Family Christian Centre to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the child/(ren) named above. I undertake and agree to indemnify and hold blameless the ministry staff and volunteers, Family Christian Centre, its pastors, and Pastor’s Council from and against any loss, damage or injury suffered by the child as a result of being part of the programs of Family Christian Centre as well as of any medical treatment authorized by the supervising individuals representing the church. I have read, understood and agree with the above and sign it to cover my child(ren)’s participation in all Children’s Ministry activities through Family Christian Centre for the 2025 program year effective as stated above.

Yes, I agree No, I do not agree

Recovering Hearts for Youth and Kids

Description

Please Fix the Following