Moms and Tots Participation Form

Stanley Park Community Church is collecting and retaining this personal information for the purpose of enrolling you and your child(ren) in this program and to inform you of program specific updates. This information will be maintained permanently as it is a requirement of our insurance company and legal counsel, but kept confidential. If you have concerns with the extent the information collected, please contact us.

Your name *

Email address *

Phone number

Address

I/We claim legal guardianship of the children named below, who will be participating, with our consent, in the Moms and Tots program run by Stanley Park Community Church *

Name of Child #1 *

Gender *

Date of Birth *

Relationship to Child *

Allergies *

Name of Child #2

Gender

Date of Birth

Relationship to Child

Allergies

Name of Child #3

Gender

Date of Birth

Relationship to Child

Allergies

Emergency Contact Name *

This should be someone who is not at the program with you and your child(ren).

Emergency Contact Relationship to you/your child *

Emergency Contact Phone Number *

Do you give permission for SPCC personnel to take photographs of your child(ren), for the sole use of promotion of SPCC programs? *

Do you wish to be added to our email list for general promotions from Stanley Park Community Church? *

Declaration *

I declare that I am aware of the risk of injury entailed with physical activity in group settings, and agree that Stanley Park Community Church and/or the United Brethren Church in Canada are held blameless and free from responsibility for any accident, injury, loss, liability, damage or cost my child may incur, however caused, and agree to release and hold harmless all instructors, staff, volunteers, and sponsors from all claims or damages, without limitation, which may arise as a result of/or by reason of such accident or loss, or any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in events of Stanley Park Community Church.