310 Mountain Avenue Killarney | Phone: 204-523-4311

Discipletown Kids Club

Family Name:
Name of Child:
Date of Birth:
Grade This Fall
Parent Phone Number:
Parent Cell Phone Number:

Alternate emergency contacts:

1. Name & relationship to the child
Alternate 1 Phone Number
2. Name & relationship to child:
Alternate 2 Phone Number:

Please give details (name, address and phone number) of other persons who you authorise to collect your child/ren in your absence, while in the care of the above-named group:


Privacy Information

This information has been collected for the primary purpose of Calvary Baptist Church and may be used for any activities conducted or promoted by Calvary Baptist Church.  If you do not want this information to be used for any other purpose other than children’s programs, please notify us in writing:

Calvary Baptist Church

c/o Cindy Hartwig 

Box 115

 Killarney, Manitoba

R0K 1G0

Permission to Participate in Program Activities


I consent to my child taking part in the approved program of activities for Adventureland - Kids Club – Calvary Baptist Church.

Permission to partake

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.

Permission to view

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 I understand that as a precaution my child’s name will not be published or linked with photographs.

Permission to be photographed

Confidential Medical Report


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

1.   Please tick if your child suffers from any of the following:

Heart condition
Other condition(s):
Is your child presently taking medication? If yes, please state the name of the medication, dosage, etc.
Does your child self-administer?
Does your child have any allergies (i.e. Penicillin, bee stings, etc)? If so, please specify.
Please list any physical or special needs (i.e. Dietary requirements)

I authorise 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 or surgical treatment, as the leader/s may deem necessary at any time during the activities of Calvary Baptist 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 Calvary Baptist Church – Children’s Ministry.  I understand that this group cannot be held responsible for personal injury, loss or theft of property affecting my child.

I consent
Parent/guardian name: