Citizens Church Edmonton - Youth Registration

Student Information

Students First Name

Student Last Name

Birthdate

Grade (current school year)

School

Does the student attend Citizens Church?

Yes

Occasionally

No

How did you hear about Citizens Youth?

Medical & Safety Information

Alberta Health Care Number - Used only in the event of a medical emergency

Does your student have allergies?

Yes

No

If yes: Please list all allergies

Does your student have any medical conditions leaders should be aware of?

Yes

No

If yes: Please explain

Does your student carry an EpiPen, inhaler, or other medication?

Yes

No

If yes: Please specify and any instructions

Are there any special needs or accommodations we should know about?

Yes

No

If yes: Please explain

Is there anything else you’d like our leaders to know to better care for your student? (Optional)

Parent / Guardian Information

Parent/Guardian #1

First Name

Last Name

Relationship to student

Please Specify Relationship to student

Phone Number

Email

Parent/Guardian #2

First Name

Last Name

Relationship to student

Please Specify Relationship to student

Phone Number

Email

Emergency Contact (Non-Parent)

First Name

Last Name

Relationship to student

Please Specify Relationship to student

Phone Number

Permissions & Consent

I give permission for my student to participate in Citizens Youth activities

I agree

I authorize leaders to seek emergency medical care if needed

I agree

I grant permission for photographs and video of my student to be used by Citizens Church for church communications, including website, social media, and promotional materials.

Yes

No

I understand and agree that Citizens Youth operates under the church’s safety policies and guidelines.

I agree

Communication Preferences

Preferred method of communication:

Email

Text

Both