Mountain View Student Ministries Registration

Parent Name

This address will receive a confirmation email

Phone

Address

Student Information

Student Name

Student Age

Student Gender

Male Female

Confidential Medical Report

The information below is requested to assist in case of any illness or accident. This information will be held in confidence.

Is your child presently taking medication? (If yes, please state the name of the medication, dosage, etc.)

Does your child have any allergies? (food/ bee sting / medication) If yes, please list.

Please list any physical or special needs: (eg. Dietary requirements)

Privacy of Information Statement

All the information recorded on this form is collected and managed with confidentiality. This information has been collected for the primary purpose of Mountain View United Methodist Church and may be used for any activities conducted or promoted by the Mountain View United Methodist Church. This information is collected solely for the safety and wellbeing of the children in our care.

Permission to Participate in Program Activities - I consent to my child taking part in the approved program of activities for the Mountain View United Methodist Church and / or Recovery at Dayton.

Yes No

Permission to View Video Tapes and DVDs - I consent to my child viewing VHS tapes or DVDs rated (G) General. I understand that all material will be previewed by a leader to check suitability. *

Yes No

Permission to be Photographed or Filmed - I give my permission for my child to be photographed or videotaped. I understand that the image may be displayed in the church publications, church buildings or website. I understand that as a precaution my child’s name will not be published or linked with photographs.

Yes No

Please check here if you do NOT wish your children to be photographed or videotaped.

Yes No

I authorize the leader/s in charge of the above mentioned group where it is impractical to communicate with me, to arrange for my child to receive such medical treatment as the leader/s may deem necessary at any time during the activities of Mountain View United Methodist Church. I further authorise the use of Ambulance and/or anaesthetic by a qualified medical practitioner if in his/her judgement it is necessary. I accept responsibility for payment of all expenses associated with such treatment. I appreciate that every care will be taken by the leaders and those connected with that group cannot be held responsible for personal injury, loss or theft of property affecting my child. *

Yes No

Signature of Parent/Guardian:

Date

Mountain View Student Ministries Registration

Description

Please Fix the Following