Roots Kids Registration and Waiver Form 2024/2025

September 2024 - August 2025

Please complete this form for your child attending our Southside Kids Sunday School and activities.

Your name *

Email address *

Household members

Please add your child/ren here. You are able to fill in one Waiver for all CHILDREN in your household. (Youth have a separate Waiver to sign).

Address *

Alberta Healthcare # of Child(ren) Participant(s) (NOT REQUIRED)

If you are filling in the Waiver for multiple children, please include the Alberta Healthcare # for each child next to their name.

Medical Concerns / Allergies / Mental Health Concerns: *

If you are filling in the Waiver for multiple children, please indicate the above for each individual child.

Parent/Guardian Contact #1: (First and Last Name) *

Parent/Guardian Contact #1 Cell Phone Number: (Please Enter a Valid Phone Number) *

Parent/Guardian Contact #1 Email Address: *

Parent/Guardian Contact #2: (First and Last Name)

Parent/Guardian Contact #2 Cell Phone Number: (Please enter a valid phone number)

Parent/Guardian Contact #2 Email Address:

Medical note

Permission/Waiver Form

Please mark the box next to each section to acknowledge your reading and agreement of each section of the waiver.

Release of Liability *

By signing this Permission/Waiver Form, I expressly warrant that the child/youth named above is capable of withstanding the physical demands of the activities discussed above. I further release and agree to hold harmless, defend and indemnify Southside Church of the Nazarene and its staff, board, trustees, volunteers and agents from and against any and all claims for personal injury (including loss of life) and all other losses or damages, except those caused entirely by the gross negligence or intentional conduct of Southside Church of the Nazarene arising from my or my child’s participation in its activities and programs.

Agree

Functions and Activities *

It is my understanding that participating in the programs and recreational and other activities at Southside Church of the Nazarene is a privilege. Prior to my child/youth’s participation in such activities, I acknowledge that there are certain risks associated with the activities including, by the way of example, physical injury due to activity related accidents, physical injury due to transportation related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

Agree

First Aid and Emergency Medical Treatment *

I recognize that there may be occasions where the child named above may be in need of first aid or medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of Southside Church of the Nazarene to seek and secure any medical attention or treatment for the child named above, including hospitalization, if in the agent’s opinion such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personal to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.

Agree

Special Events and Field Trips *

I understand that the child/youth named above will be participating in various Southside Youth Ministry activities from 1 September 2024 to August 31 2025. I understand that during this period my child/youth may take part in activities off church property such as: city wide events, Youth trips, Youth Conferences, Missions Trips and other activities consistent with the purposes of the church. I also understand that I may be asked to sign Special Permission Slips in addition to this form. I give permission for my child to leave church property for Southside Youth Ministry events and/or to ride in any vehicle designated by the approved adult leadership while attending and participating in activities sponsored by Southside Youth Ministry.

Agree

Publicity *

On occasion, Southside Church of the Nazarene takes photographs or makes an audio or video tape recording of children, youth and or adults involved in church activities. Such photographs or video recordings may be used by staff and participants to remember the activities or participants. In addition, such photographs and audio/visual recordings may be used in Southside Church of the Nazarene publications, social media or advertising materials to let others know about our ministry. I consent to the use of any such, audio or visual record of the child named above to be used, distributed, or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings.

Agree

Disagree

General Release *

I hereby release and agree to hold Southside Church of the Nazarene harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act, of Southside Church of the Nazarene, or that may otherwise arise in any way in connection with any Southside Church of the Nazarene activities. I understand that this release discharges Southside Church of the Nazarene from any liability or claim that I, my heirs, or any personal representative may have against Southside Church of the Nazarene with respect to any bodily injury, illness, death, medical treatment or property damage that may arise from, or in connect to, any activities related to Southside Church of the Nazarene. This liability waiver and release extends to the Southside Church of the Nazarene together with all staff, board and volunteers.

Agree

Parent/Guardian Authorization

I represent that I am the parent/guardian of the above child(ren), who is(are) under 18 years of age. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof. I give permission for the child named above to participate in the activities of Southside Church of the Nazarene, including any special events/activities described above. In consideration for allowing the participation of the child in the activities of Southside Church of the Nazarene, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the child, and agree that this Permission/Wavier Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns. I also understand that it is my responsibility to see that the information on this form is updated when there is any changes in my child’s/youth/s medical status, etc.

By signing I agree I have read and filled out all information on this waiver to the best of my ability.

Emergency Contact Info *

Please include a minimum of ONE EMERGENCY CONTACT and relationship to child/youth etc.

Parent/Guardian Signature *

By typing my name in this space I agree to all of the above.

Date Signed *

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