Registration and Medical Consent Form

Information received is confidential and is being gathered for the purposes of serving your Child while in the care of Northwest Langley Baptist Church. Any medical information collected here serves to authorize Northwest Langley Baptist Church, and its staff and volunteers, to obtain medical assistance in emergencies.

For the School Year 2026/2027

In the case of custody agreements, please include the proper form authorizing Parental contacts.

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Student's Name

Date of Birth

Address

Parent/Guardian Phone

Health Card Number

Family Doctor

Doctor's Phone

Allergies

Who to contact in case of emergency! Please leave detailed instruction

Does your child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of? If yes, please explain:

Is your child bringing any medication with them? 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 parent(s) or legal guardian(s) named below, authorize Forough Mosayebi or another authorized Organization Ministry Personnel to provide consent for emergency medical assessment and treatment for the participant named above. This authorization applies only in the event of an emergency when the parent(s)/guardian(s) or emergency contact cannot be reached. I/we authorize any physician, hospital, or other qualified healthcare professional to provide necessary medical assessment and treatment.

Initial

I/we, named below, undertake and agree to indemnify and hold harmless Ministry Personnel, Organization, 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 Organization, as well as of any medical treatment authorized by the supervising individuals representing Organization. This consent and authorization is effective only when participating in or traveling to events sponsored by Organization.

Initial

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 your child via telephone, email, social media and text:

Telephone Email Social Media Networks Text Messages None

Initial

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 None

Initial

Purposes and Extent

Northwest Langley Baptist 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 Northwest Langley Baptist 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 above and sign it to cover all Children/Youth 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 / Guardian Signature

Parent / Guardian Name

Date

Registration and Medical Consent Form

Description

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