Rooted Youth Registration and Medical Consent Form

Information received is confidential and is being gathered to serve your Child while in the care of Calvary Pentecostal Church. Any medical information collected here serves to authorize Calvary Pentecostal Church, its staff and volunteers to obtain medical assistance in emergencies.

For the school year 2025 / 2026

Write NA if not writing Child’s Health Card #

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Write NA if not writing the name of the Family Doctor

Write NA if not applicable

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Does your child have any physical, emotional, mental, or behavioural concerns or limitations that staff/ volunteers should be aware of?

If yes, please explain:

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Is your child bringing any medication with them?

The safety of your child is our primary concern.  Precautions will be taken for their well-being and protection.

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Medical Consent

I/we, the parents or guardians named below, authorize Pastor Luke Benjamin or one of Calvary Pentecostal Church’s Ministry Personnel 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 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 are effective only when participating in or travelling to events sponsored by Calvary Pentecostal Church.

Purposes and Extent

Calvary Pentecostal 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 for Calvary Pentecostal 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/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.

Signature