Event Permission & Health Form

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Please complete this form in order for your Child to partake in DYM events

In ticking the below box you confirm that you are the parent or guardian of the child this form is for. If you are not the parent or guardian please give this form to them to fill out. If you completing this form as a leader or are the age of 19 and therefore considered legally an adult, you can click 'other' and describe your role. *

Yes, I confirm that I am the parent or guardian of this child, stated below

Other:

Required

Child's First and Last Name (Or yours if over 19) *

Child's Pronouns *

Child's Date of Birth (Or yours if over 19) *

YYYY

PHN number *

Emergency Contact 1: Please give name, relationship and contact telephone number: *

Emergency Contact 2: Please give name relationship, and contact telephone number:

Allergies and health concerns we should be aware of: *

Consent for Participation: As the parent or guardian I hereby give consent for my child to participate in online and in person events. Online events will take place on Zoom or similar. For in person gatherings, when safe to do so, participants will be properly supervised in all activities. In the event of accident or illness, the Diocesan Youth Movement, and the Diocese of New Westminster, its staff and volunteers are released from any liability. In the event of injury or illness requiring medical attention, by ticking the box below I authorize appropriate treatment for the participant and understand that reasonable attempts will be made to contact me, should such a situation occur. The participant must be covered by provincial health insurance or equivalent medical coverage. *

Yes, I authorize for my child attend this event and agree to the above waiver.

Other:

At Events held by the Diocesan Youth Movement or wider branches of the Anglican Church, our leaders or leaders associated with these organizations may be taking photos or videos of young people for publicity purposes, these may be used on websites, in publicity materials and in related publications, such as newsletters. Pictures and videos may also be used on some forms of social media for publicity as well, these may include, Facebook, Instagram or YouTube. Please indicate below the level of consent you grant for this. By signing this release, you permit the Diocesan Youth Movement, the Diocese of New Westminster and the Anglican Church of Canada to use your name and photograph in all forms of media which may result from events attended and waive the right to approve the finished product. *

Yes I give permission for my child's photo AND name to be used

Yes I give permission for my child's photo to used - but not their name

No, I do not grant permission.

Permission for Diocesan Youth Events: I give permission for my child to be contacted regarding this and future events related to the youth ministry of the Diocese of New Westminster:

I give permission

I do not give permission

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Is there anything else you think we should be aware of?

Thank you from all of us at the DYM for taking the time to complete this form!

Lauren Odile Pinkney | Chair of DYM | lauren@thecathedral.ca
Rev. Jessica Schaap | Missioner for Christian Formation | jschaap@vancouver.anglican.ca

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