Phone number *
Phone type Mobile Home Work Other
What is your relation to the child/children you are registering? *
If you select the 'Other' option, please provide details in the space provided.
Select… Mother Father Guardian Other
Household members
Click "+ Add adult" to add each adult who resides with you and may bring a child from your household to an event or program. Click "+ Add child" to add each household child from newborn to 12 years. Note: The medical information gathered here serves to assist and authorize Harvest City Church, its staff and/or volunteers to obtain medical assistance in case of emergency. In the MEDICAL NOTES field, include anything that program leaders should be aware of. Examples: allergies, special needs (physical/emotional/behavioral concerns), and/or emergency medications the child carries with them. Type NONE if not applicable.
+ Add adult + Add child The child/children live with: *
Are there any custody issues that we should be aware of? *
If there are custody issues, choose "Other" and give a brief explanation.
Select… No Other
Are the child/ren's biological and/or foster parents listed as adults in this Household?
If they're not, select "Other" and type the first and last name of the biological or foster parent as well as their phone number.
Select… Yes Other
Trusted People
List people you trust to drop off and/or pick up your child(ren).
Unauthorized People
List anyone who is NOT permitted to drop off and/or pick up your child(ren).
Photo/Video Release *
"I give permission for Harvest City Church to use any photographic, audio or video recording of me or my children for identification, security, promotion, or any Harvest City Church use. I acknowledge that these photos and/or recordings will be stored on the Harvest City Church computer system for these purposes. I understand my consent is valid indefinitely unless I in writing notify Harvest City Church that I revoke my consent or request removal of photos, recordings, or personal information from Harvest City Church sites or publications prior to their publication. I further release and hold harmless Harvest City Church from any and all liability that may result from the release and/or use of the above-mentioned information."
Harvest City Church believes in excellence in our entire Children’s & Youth Ministry Departments. It is always our endeavour to care for your young people to the best of our ability while they are entrusted to us. Their safety is our primary concern; precautions will be taken for their well-being and protection. However, we do assume responsibility for the care only when complete information regarding allergies, any other special needs, etc. is provided. That’s why we require that you submit this form. If your young one’s situation changes from week to week, please ensure that the changes are communicated directly to the Personnel in charge of the event they are attending (for example, their Sunday School teacher). At any time we reserve the right to not admit your young person into a children’s or youth event if there are signs of any communicable disease or sickness (e.g. colds), etc. At Harvest City events that provide child care, children from newborn to age 5 must be dropped off by a parent/guardian and will only be released to a person authorized by a parent/guardian. We reserve the right to remove children who exhibit extreme or rebellious behavior that negatively impacts our ability to care for the group in its entirety. We appreciate you collecting your child(ren) immediately after the end of the meeting/event you’re attending.
I/we, named herein, authorize Harvest City Church's pastors or other program personnel to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment, or procedures for the child(ren) named above. I/we, named herein, undertake and agree to indemnify and hold harmless Harvest City Church, it's program personnel and leaders from and against any loss, damage, or injury suffered by the child(ren) named above as a result of being part of the activities of Harvest City Church, as well as of any medical treatment authorized by the supervising individuals representing Harvest City Church. This consent and authorization is effective only when participating in or traveling to or from events sponsored by Harvest City Church. For a child to participate in Harvest City Church activities, at least one Parent or Guardian with permission to care for them must agree below.
Consent *
By typing your full name you are indicating you have read and agreed to all of the above, and the information you have provided is true to the best of your knowledge.
Submit A copy of your responses will be sent to your email address.