* Child's Name
* Parent's Name
* Phone Number
What is the best way to reach you?
Alternate Contact Name
* Alternate Contact Name
Alternate Contact Number
* Alternate Contact Number
If yes, which church?
Is there a medical condition we should be aware of while your child is involved in our summer day camp?
Does your child have any food allergies?
Does your child child carry an EpiPen that may need to be administered in case of emergency? If so, please let us know what the emergency may be and any special instructions:
Are there any other special instructions our staff should be aware of concerning your child? (i.e. fears, social concerns, behaviour issues)
Please list the names of children that your child would like to be placed in a group with. We will try our best to match friends together
Additional information not covered by the form:
1. The names and addresses of children and their parents or guardians will be carefully maintained, updated annually and kept permanently in a central file.
2. A release and permission statement will be included on all registration forms releasing the church from unforeseen and accidental damages along with contact information in case of an accident. I/We, the parents/guardians authorize the ministry staff of Kitchener Gospel Temple 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 blameless the ministry staff, Kitchener Gospel Temple, its Pastors and Board of Elders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the Kitchener Gospel Temple, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to Kitchener Gospel Temple's Summer Half-Day Camp.
3. Purposes and Extent: Kitchener Gospel Temple 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 permanently as it is a requirement of our insurance company and legal counsel. If you wish Kitchener Gospel Temple to limit the information collected, or to view your child’s information, please contact us.