Pathway Kids Registration Form

Pathway Life Church is collecting and retaining this personal information for the purpose of enrolling your child/student in our programs, assigning them to the appropriate group, and to develop ongoing relationships with your family.

Child Info

First Name *

Last Name *

School Grade

Tip: Enter current grade, or in July-August enter last grade completed

Date of Birth *

Gender

Allergy/Health Concerns

The safety of your child/student is our primary concern. Precautions will be taken for their well-being and protection. Information received is confidential and is being gathered for the purposes of serving your child while in the care of Pathway Church.

Does your child any physical, emotional or behavioural concerns/limitations that our staff should be aware of. *

Yes

Medical / Allergy

Tip: Leave blank if N/A

Please list any physical, emotional or behavioural concerns/limitations that our staff should be aware of:

Contact Info

Mailing Address *

Mailing City *

Email Address *

Mailing Address Line 2

Mailing Postal Code *

Mobile Number *

Parent/Guardian Info

Parent/Guardian #1

First Name *

Last Name *

Relationship to Child *

Parent/Guardian #2

First Name

Last Name

Relationship to Child

Media Consent

I grant Pathway Church, its representatives, and employees the right to take photographs, videos, and/or electronic images of any member of my family in the Pathway Kids environment. I authorize Pathway Church to use and publish the photographs, videos and/or electronic images in print and electronically for any lawful purpose to highlight and promote the Pathway Kids environments and program. Personal information will never be displayed with any image (ie. name, age). By selecting 'Yes' below, I indicate that I have read and understood the above statement of release.

Media Release *

Yes

Parent / Guardian Consent:

I have read, understood and agree with the above and sign it to cover all Pathway Kids activities for the current program year (September to September), including large group gatherings and small group activities in host homes/parks/public spaces.

I/we undertake and agree to indemnify and hold harmless ministry personnel, Pathway Church, and its volunteers from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Pathway Church, as well as of any medical treatment authorized by the supervising individuals representing Pathway Church.

Name of Parent/Guardian Giving Permission *

Date of Permission *