Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cellphone Number *

if you number is too long please omit the first 0 of your number, so 0204 123 4567 becomes 204 123 4567

(###)

###

####

Home Phone Number *

(###)

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School Year *

6

7

8

9

10

11

12

13

University

Other

Emergency Contact Name *

First Name

Last Name

Emergency Contact Number *

(###)

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Swimming Confidence Level

Unconfident

Moderately Confident

Very Confident

The Parents or Guardians of the Participant, hereby authorize and consent to the Participant’s involvement in the St Chads Church and Community Centre youth program – “Legacy Youth’, including any use of private or public transportation deemed necessary by the persons in charge of the Youth Group for Participant travel to and from Youth Group activities, or to the nearest suitable medical or hospital facility in the event that emergency or other medical treatment not available at the site of a Youth Group activity is deemed advisable. We hereby consent to and authorize such emergency or other medical treatment of the Participant as may be deemed advisable in the event of accident, injury, or illness during the activities of the Youth Group. We also understand that the participant may be photographed or appear in video for any purposes St Chads Church and Community Centre deems. *

I agree

I disagree

I understand St Chads Church and Community Centre (St Chads) and its leaders, staff, volunteers, and representatives are not responsible for any injury, loss or damage of any kind whatsoever sustained by any person or their property while participating in events, activities or travel with St Chads Church and Community Centre. *

I agree

I disagree