Child & Youth Info Form, Rev. 3 • First Baptist Church, Guelph

Today's Date *

Child's First Name *

Child's Last Name *

Preferred Pronouns *

Date of Birth *

School Grade (2025/2026 year) *

Health Card Number (include version code) *

Allergies/Medical/Behavioural Concerns (if required, please list medications and bring these medication in their original containers to the event/camp with written instructions on how and when your child should take them):

Allergies/Medical/Behavioural Concerns

Parent/Guardian Name(s) *

Home Address *

Home City *

Home Province *

Home Postal Code *

Phone Number *

Email Address *

Mobile Number

Emergency Contact Name(s): *

Phone Number *

Relationship to Child *

Authorized for Pick-Up - they may be asked for photo ID

Name and Relationship to Child

I give my permission for my child to be photographed for the purpose of promotion and programming: *

I understand that it is my responsibility to ensure that my child will not share pictures of other children online: *

In the event that the child named above suffers an accident during the activities of an event run by First Baptist Church, I acknowledge that the Church has made every reasonable effort to ensure safety, and therefore, I do not hold the staff, the volunteers of the Church and its members responsible. I further authorize the adult volunteers of First Baptist Church to act as agents for the undersigned to transport in a private vehicle/taxi/emergency response vehicle this child to a healthcare facility and see appropriate medicl care from the required healthcare providers as registered by the Ontario Medical Association. I further release from liability First Baptist Church, Guelph and any of its leaders/volunteers, in the event of an accident en route, during and returning from trips and/or activities associated with the day camp. This agreement does not apply to claims for intentional misconduct and/or gross negligence.

I am the guardian for this child and I agree to the above statement. I agree that I have completed this form to the best of my knowledge. I agree that if I have shared my chiId's personal contact information, they will receive correspondence regarding youth related activities. I acknowledge that by agreeing to this statement, it will used in lieu of my signature. *