registration form

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GIRLS’ CLUBS & C.S.B. CLUB REGISTRATION FORM (one form per child) CHILD’S NAME ADDRESS

_____ HOME PHONE ______________________________ CITY

_____ Postal Code ____________________

BIRTHDATE (m/d/y) __________________________AGE __________ SCHOOL GRADE _______ GENDER:

M

F (circle)

FATHER’S NAME ________________________________ MOTHER’S NAME ____________________________________ FATHER’S CELL PHONE # ________________________ MOTHER’S CELL PHONE # _____________________________ HOME EMAIL ADDRESS _________________________________________________________________________________

PARENTS’ OR GUARDIANS’ CONSENT: I___________________________________________ the parent of ________________________________________ consent to his/her participation in the club programs by Calvary Baptist Church. I understand that by permitting my child to be included in this program, I agree that Calvary Baptist Church and anyone acting on its behalf, will be released from any liability for injuries to my child that may be occasioned on this activity and that I give permission to the leaders of this group at Calvary Baptist Church to make decisions in case of an emergency on behalf of my child when I am not immediately available for consultation. (We will try everything possible to contact you, in case of emergency.) Signature of Parent or Guardian: _________________________________________ Phone: ____________________

Emergency contact person: _____________________________________________ Phone: ____________________ Note: (OTHER THAN PARENTS) Special Health Needs (i.e. allergies, asthma, diabetes, etc.) ________________________________________________ _______________________________________________________________________________________________ Special behavioural / emotional / physical needs. Please explain: __________________________________________

_______________________________________________________________________________________ Do you regularly attend a local church? (circle one) yes Were you registered last year?

no

YES

If yes, what church? NO

___________________________

(Please circle one) AMOUNT

Registration Fee

$

10.00

Club Achievement Book

$

15.00

T-Shirt

$

15.00

MAKE CHEQUES PAYABLE TO: Calvary Baptist Church (Separate cheques are required for boys and girls)

Total $

OFFICE USE ONLY Club Group assigned to:

Date:

T-SHIRT: Shirts are given out at registration.

Tadpole T-Shirt (boys and girls in JK and SK): one size fits all Treeclimbers T-Shirt (boys Gr. 1 and 2): one size fits all Stockade Builder T - Shirt (boys Gr.3-4): all sizes available Stockade Sentinel T-Shirt (boys Gr.5-6): all sizes available Girls’ Clubs T-Shirt (girls Gr.1-6): all sizes available

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