Children's Ministry Registration Form

Peterborough Free Methodist Church – 2023-2024

Please fill out the online form below; please indicate N/A in areas that do not apply.  OR download this document fill it out and bring it to the church. 

(One form per student to be completed for anyone under the age of 18)

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

I am registering my child for:*

Sunday School

Circle of Friends

Both

Biographical Data

Student's Name (first & last)*

Email- please put N/A if not applicable*

School*

Birthday*

Age*

Grade*

Please select one of the following:

M

F

Family Data

Student Lives with (please select from drop down list):*

Both ParentsFatherMotherOtherOther...

If "Other", please specify

Parent(s)/Guardian(s) Name(s):*

Address*

City*

Postal Code*

Home Phone*

Work Phone*

Cell Phone*

Email- please put N/A if not applicable*

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Relationship to Student*

Emergency Contact Home Phone*

Emergency Contact Cell Phone*

Secondary Address of Student (If Student resides at least partially with another parent or guardian)

Name

Address

City

Postal Code

Home Phone

Work Phone

Cell Phone

Medical Information

Health Card #*

Family Doctor*

Allergies*

Medical Condition/Special Needs*

No

Yes

List any Special Needs: eg ADD, ADHD, ASTHMA, EPILEPSY

Additional Information that we should be aware of:

Photos/Videos

Occasionally pictures and video are taken to capture memories of certain events and to share with the rest of the congregation. Pictures and videos may be used for the purpose of promotional material on the church website and Facebook page, or in our worship services that are live streamed on Youtube. Please indicate your permission below:*

All (Facebook/website/church)

Church use only

No

Custody Orders or Issues

Please list names of persons NOT AUTHORIZED to pick up your child. Indicate First & Last Name and Relationship to student (*Please Note: All children six and under must be signed in for programs)

I, named below, undertake and agree to indemnify and hold blameless Peterborough Free Methodist Church, its personnel, its Directors and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the Peterborough Free Methodist Church, as well as of any medical treatment authorized by the supervising individuals representing the church. I have read, understood and agree with the above.*

Agree

Disagree

I/we, the parents or guardians named above, authorize Holly Raymond or her designate 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 in the event of an emergency. While every precaution will be taken to ensure the safety and protection of your child, Peterborough Free Methodist Church, its pastors, representatives and Board of Elders are hereby released from any and all liability in the event of loss, damage, or injury suffered by the participant as a result of being part of the activities of the Peterborough Free Methodist Church. *

Agree

Disagree

Enter the code displayed*