Page 1 of 3

West Zion Youth Authoriziation & Medical Consent Form

Information received is confidential and is being gathered for the purposes of serving your child while in the care of West Zion Mennonite Church. Any medical information collected here serves to authorize West Zion Mennonite Church, and its staff and volunteers, to obtain medical assistance in emergencies. West Zion Mennonite 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 Church. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish West Zion Mennonite Church to limit the information collected, or to view your child’s information, please contact us.
Student's Name:*
Invalid Input

Student's Birthdate (include year of birth):*
Invalid Input

Student's Address:*
Invalid Input

Student's Phone Number:
Invalid Input

Student's eMail Address:
Invalid Input

Mother's Phone Number:*
Invalid Input

Father's Phone Number:*
Invalid Input

Best Parent eMail Address:*
Invalid Input

May we send you a weekly eMail/Text reminder? *
Invalid Input

 
Student's Doctor & Phone Number:*
Invalid Input

Alberta Health Care #:
Invalid Input

Medications, allergies or physical, emotional, behavioural, mental concerns or limitations that our volunteers/staff need to be aware of:*
Invalid Input

Emergency Contact:*
Invalid Input

 
Parent's/Guardians' Names:*
Invalid Input

The safety of your student is our primary concern; precaution will be taken for their well-being and protection.
I/we, the parents or guardians named above, authorize the Pastors of West Zion Mennonite Church or one of the West Zion Mennonite Church Ministry Volunteers to sign 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 above, undertake and agree to indemnify and hold blameless the Pastors of West Zion Mennonite Church, the Ministry Volunteers, West Zion Mennonite Church, its Pastors and Board of Elders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the West Zion Mennonite Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to events of the West Zion Mennonite Church.
Please indicate using the boxes to grant your permission for reasonable use of photos containing your child in any or all of the following ways:*
Invalid Input

I agree that my signature will be valid for this Consent Form for the years 2017 through and including 2023 or until my student turns 18 years of age:*
Invalid Input

Please mark today's date:*

Invalid Input

Parent/Guardian Signature:*
Invalid Input