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Gospel Centre Church Student Registration Form
Student's Last Name
Student's First Name
Home Phone Number(s)
Student's Cell Number
Student's Email Address
First Parent/Guardian's First Name
First Parent/Guardian's Last Name
Address, if different than above
First Parent/Guardian's Cell Phone
First Parent/Guardian's Email Address
Second Parent/Guardian's First Name
Second Parent/Guardian's Last Name
Address, if different than above
Second Parent/Guardian's Cell Phone
Second Parent/Guardian's Email Address
Student's Date of Birth
Alberta Health Card Number
Allergies - Does this student have any allergies that we should be aware of? Please list them below:
Do you have any special instructions or physical, emotional, mental, or behavioral concerns/limitations for this student that we should be aware of?
How did you hear about REVOLVE Youth?
What church do you attend?
Would you like to be involved with REVOLVE Youth in any of the following areas? (Check all you are interested in.)
Would you like to receive weekly texts with current week REVOLVE event information?
If Yes, enter preferred cell number: _________________________________________________________________________________
PERMISSION: Do we have your permission to follow up with your student via text?
INFORMED CONSENT: In the event of an emergency where medical treatment is required, I give permission to the church staff and/or sponsors to obtain services for treatment as deemed necessary if I cannot be contacted in a reasonable amount of time. Further, I will hold harmless or indemnify Gospel Centre Pentecostal Church for any loss or injury that may be sustained. I recognize that there are risks inherent in activities my child may be engaged in and, again, I waive, hold harmless, or indemnify Gospel Centre Pentecostal Church, its instructors, paid or volunteer staff, successors, heirs, and assigns from any action.
WAIVER: I hereby give permission for my child to be photographed and/or filmed without any reimbursement of any kind due to me or the need to pay any fee. Gospel Centre Pentecostal Church considers all information personal and confidential and will only use it within the church for ministry or other church related activities and will not release it to outside parties or organizations.
COVID-19: **READ CAREFULLY BEFORE SIGNING** ALTHOUGH THIS WAIVER IS REQUIRED TO ATTEND, BY SIGNING THIS FORM YOU MAY BE WAIVING CERTAIN LEGAL RIGHTS YOU AND/OR YOUR DEPENDENTS MAY HAVE. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I (and my children) may be exposed to or infected by COVID-19 by attending Gospel Centre Pentecostal Church, and that such exposure or infection may result in personal illness, injury, permanent disability, or death. I understand that if I am 60 years of age or older, or if I am immunocompromised due to medication or an existing health condition or disease, I may be more susceptible to death or serious illness from COVID-19 and am taking increased measures to avoid infection, including wearing a face mask, social distancing or participating in online services. I understand that the risk of becoming exposed to or infected by COVID-19 at ABC COMMUNITY CHURCH may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Gospel Centre Pentecostal Church employees, volunteers, attendees, program participants and their families. I agree while on premises or while participating in off-premises activities events of Gospel Centre Pentecostal Church to abide by all rules and recommendations posted in signs on the premises and otherwise communicated in writing or verbally by Gospel Centre Pentecostal Church, its directors, officers, employees and volunteers, to protect my health and safety, including minors in my care. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any illness or injury to myself (or to my children), including, but not limited to, personal injury, disability, death, damage, loss, claim, liability, or expense, of any kind, that I (or my children) may experience or incur in connection with my (or my children’s) attendance at Gospel Centre Pentecostal Church or participation in its events, programs or activities. On my behalf (and on behalf of my children), I hereby release, covenant not to sue, discharge, and hold harmless Gospel Centre Pentecostal Church, its officers and directors, members, employees, volunteers, agents and representatives, of all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any all liabilities, claims, actions, damages, costs or expenses of any kind based on the actions, omissions, or negligence of Gospel Centre Pentecostal Church, its directors or officers, employees, volunteers, agents and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Gospel Centre Pentecostal Church program or activity.
OFF-SITE PERMISSION: I/We, the undersigned parent(s) or legal guardian(s) for the named child above, give our permission for our child to participate in onsite or offsite events between July 8th, 2020 and August 31, 2021. We also give permission for any representative of Gospel Centre Pentecostal Church to obtain any necessary medical treatment as needed while offsite. We assume responsibility for any medical bills incurred and should our child have to return home before the group for medical or disciplinary reason, we also hereby assume any cost incurred. We give authorization for the previously mentioned to provide all necessary food, transportation, and lodging as applicable. We do hereby release, forever discharge and agree to hold harmless, Gospel Centre Pentecostal Church, its pastors, staff, and representatives thereof from any and all liability claims, or demands for personal injury, sickness, or death, as well as property damage and expenses of any nature whatsoever which may be incurred by my child in the course of participation in the aforementioned. Furthermore, we agree to assume all responsibility for any of the previously mentioned occurrences.
Emergency Contact Name
Emergency Contact Number
Gospel Centre Pentecostal Church considers all personal information as confidential and will not release it to outside parties or organizations. However, by completing this form, you are providing consent for this information to be used within the church for ministry and other church related activities. when using photos of Gospel Centre events, either on our website or on Gospel Centre's Facebook page, we try to post photos that would not be considered objectionable. We will remove any photo immediately upon request.