After School Program: Fun at Cornerstone Kids

Information received is confidential and is being gathered for the purposes of serving your Child while in the care of Entwistle Community Church. Any medical information collected here serves to authorize Entwistle Community Church, and its staff and volunteers, to obtain medical assistance in emergencies. This form should be completed annually by a guardian with the child in their care

Childs Date of Birth *

Phone Number (Primary) *

Guardians Work Number

Family Doctor

Doctor Number

In case of an emergency contact: *

Number *

Does your Child have any physical, emotional, mental, behavioral concerns or limitations that staff should be aware of? *YesNo

If yes, please explain:

Is your Child bringing any medication with him/her?* *YesNo

If yes, to medication please explain:

The safety of your Child is our primary concern. Precautions will be taken for their well-being and protection. I/we, the Guardians listed below, authorize the Youth Coordinator, or one of Entwistle Community Churches Youth/Children Personnel to sign a consent form for medical treatment and authorize any physician or hospital to provide medical assessment, treatment, or procedures for the participant named above. I/we, the Guardians listed below, also undertake and agree to indemnify and hold harmless Ministry Personnel, Entwistle Community Church, and it’s leaders against any loss, damage, or injury suffered by the participant as a result of being part of Entwistle Community Church , as well as of any medical treatment authorized by the supervising individuals representing Entwistle Community Church. The consent and authorization is effective only when participating in or travelling to events sponsored by Entwistle Community Church. I/we, the Guardians listed below, consent to our child attending the program Cornerstone Kids at Entwistle Community Church. Knowing it may entail: devotional times, snack time, game time (indoor and outdoor on the Entwistle Community Church property), craft time, music, and interaction with other kids who attend.

Communication: A policy is in effect that communication is to be used solely for the dissemination of information. Please sign below to grant permission for Ministry Personnel (staff and volunteers) to communicate with you via monitored telephone, email, social media, and text (check all that apply):

CommunicationTelephoneEmailSocial Media NetworksText Messages

Photos: Please sign below to grant permission for the reasonable use of pictures containing your Child in any or all the following ways (Your child’s name will not be used):

Purposes and Extent: Entwistle Community Church is collecting and retaining this information for the purpose of enrolling your child into our program, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you or your child, and to inform you of program updates and upcoming opportunities at our organization. The information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you with Entwistle Community 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 all listed above and sign it to cover all the Children’s activities for the program: Cornerstone kids; year effective listed below. A separate informed letter of consent will be issued for offsite activities and activities of elevated risk.

Cornerstone Registration and Consent Form

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