Online Consent Form: Youth Ministry Appendix 9b - Youth Ministry Registration & Medical Consent Form These forms have been adapted from Plan to Protect®, permission granted by Plan to Protect® 2023© for use by Shuswap Community Church. *Denotes Required Field * Title I/we, the parents or guardians named below, authorize the Children's or Youth Ministry Leader or one of Shuswap Community Church Ministry Personnel to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assistance, treatment or procedures for the participant named above. I/we, named below, undertake and agree to indemnify and hold harmless Ministry Personnel, Shuswap Community 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 Shuswap Community Church, as well as any medical treatment authorized by the supervising individuals representing Shuswap Community Church. This consent and authorization is effective only when participating in or travelling to events sponsored by Shuswap Community Church. COMMUNICATION A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Children/Youth Program Ministry Personnel (staff and volunteers) to communicate with you and/or your child/youth via telephone, email, social media and text: Telephone Home Work Cell Email Social Media Networks Text Messages PHOTOS Please sign below to grant permission for the reasonable use of pictures containing your child in any or all of the following ways: Brochures/Promotional Material Website Videotaping Church Newsletters PURPOSES & EXTENT Shuswap Community Church 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 organization. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Shuswap Community Church to limit the information collected, or to view your child's information, please contact us. PARENT/GUARDIAN OPTIONS I have read, understood, and agree with the above and sign it to cover all Children Program activities for the program year effective as stated below. A separate Letter of Informed Consent will be sent home for off-site activities and activities of elevated risk. * Parent Signature * Date Signed Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 Youth Ministry Registration & Medical Consent Form Information received is confidential and is being gathered for the purpose of serving your Child while in the care of Shuswap Community Church. The safety of your child is our primary concern. Precautions will be taken for their well-being and protection. Any medical information collected here serves to authorize Shuswap Community Church, and its staff and volunteers, to obtain medical assistance in emergencies. In the case of custody agreements, please include the proper form authorizing Parental contacts. * Parent(s) / Guardian Name * Address * City * Province * Postal Code Home Number ( ) - * Cell Number ( ) - Work Number ( ) - Family Doctor Phone Number ( ) - * Emergency Contact * Phone Number ( ) - Youth attending one of our programs for the current school year: * (1) Name of Child * (1) Date of Birth Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 * (1) Age * (1) Program * (1) Health Card Number * (1) Allergies (1) Does your child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of? Yes No * Please Explain (2) Name of Child (2) Date of Birth Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 (2) Age (2) Program (2) Health Card Number (2) Allergies (2) Does your child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of? Yes No Please explain Do you have another child to register? Yes No (3) Name of Child (3) Date of Birth Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 (3) Age (3) Program (3) Health Card Number (3) Allergies (3) Does your child have any physical, mental, behavioural concerns or limitations that staff should be aware of? Yes No Please Explain Do you have another child to register? Yes No (4) Name of Child (4) Date of Birth Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 (4) Age (4) Program (4) Health Card Number (4) Allergies (4) Does your child have any physical, mental, behavioural concerns or limitations that staff should be aware of? Yes No Please Explain