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Registration Entry

Grade 5&6 Registration

Student Information

Campus

Campus is required.

First Name

First Name is required.

Last Name

Last Name is required.

Email

Email address is not valid

Email is required.

Mobile Phone

Birthdate

/ / Birthdate cannot be a future date.

Gender

Male Female

Gender is required.

Address

Home Phone

School

Grade (as of September 2022)

Alberta Health Care #

Custody Concerns

Yes No

Custody Concerns is required.

Do you have a friend who attends Centre Street Church? Please indicate first and last name below

Medical Information (Allergies/Restrictions)

Parent/Guardian Information

Parent 1

Relationship to student

Father Mother Step-Parent Legal Guardian Other

Relationship to student is required.

First Name

First Name is required.

Last Name

Last Name is required.

Cell Phone

Cell Phone is required.

Work Phone

Email

Email address is not valid

Email is required.

Custody

None Sole Shared

Parent 2

Relationship to student

None Father Mother Step-Parent Legal Guardian Other

First Name

Last Name

Cell Phone

Work Phone

Email

Email address is not valid

Custody

None Sole Shared

Informed Consent Agreement

I, the parent or legal guardian names on this registration, give permission for:
(a) The student named on this form to participate in the Centre Street Church Grade 5&6 Ministry Program, and
(b) Staff members of Centre Street Church to authorize any physician to hospital to provide medical assessment, treatment, or procedures for the student if necessary while the student is participating in the Centre Street Church Grade 5&6 Ministry Program.
I understand that the personal information in this form is being collected for the purpose of enrolling my Student in the Centre Street Church Grade 5&6 Program, to assign the Student to the appropriate groups, to develop and nurture ongoing relationships, and to inform me of program updates and upcoming opportunities in Grade 5&6 Ministries and Centre Street Church via digital and online media. Attendance for students involved will be collected and stored for all groups, events, retreats and other Grade 5&6 Ministry gatherings.
I understand that my personal information is protected under the Personal Information Protection Act.

I have read and agree to the Informed Consent Agreement

YesI have read and agree to the Informed Consent Agreement is required.

Parent/Guardian Name

Parent/Guardian Name is required.

Today's Date

Today's Date is required.

Submit