* Child's Name

* Date of Birth (month/day/year)

* Grade in School

* Parents/Guardians Names

* Child's Address

* Phone Number (home)

Mom's Cell

Dad's Cell

Email

* Preferred Method of Communication

* Family Doctor (please include phone number)

* Allergies - Please list any allergies your child may have. If none, please answer "none".

* Does your child carry a puffer or episode-pen? If so, please provide instructions in writing regarding its' use. Please note that STEM Club staff will follow your instructions regarding administration of these two forms of medication. Staff are not permitted to administer any other forms of medication for your child.

* Does your child have any physical, emotional, or behavioural concerns or limitations that we should be aware of? Please note that the dignity of each child will be respected and supported at all times.

* Please sign below to grant permission for the reasonable use of pictures/video containing your Child in all of the following ways: Brochures/Promotional material, website, organization & newsletters.

* Medical Permission - I, the parent or guardian named above, authorize a Community Bible Church staff or volunteer to sign a consent for medical treatment and to authorize a physician or hospital to provide medical assessment, treatment, or procedures for the participant named above in the event that I cannot be reached.

* By giving my name below, I agree to indemnify and hold blameless, Granton Community Bible Church, including all volunteers, Staff, and Board of Elders from any loss, damage or injury suffered by my child as a result of being part of STEM Club, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to or from events of Community Bible Church.