EmailMe Form - Bethel Registration/Medical Form

Participant's Name *

First Last

This form is being submitted for the following activity and/or group(s):
(check all that apply) *

School grade or Preschool Class (as of Sept 2022) *

Gender *

Male

Female

Participant's Birth Date *

MM / DD / YYYY

Participant's Address *

Street Address City State / Province / Region Postal / Zip Code

Participant's Home Phone *

### - ### - ####

Participant's Cell Phone
(YM2 only)

### - ### - ####

Cell Phone Permission

Please indicate if you allow your child to receive texts from a Bethel employee related to YM2 or Youth Group (ie. reminders, Bible verses and discussion topics) *

Yes, I give permission.

No, I do not give permission.

If your child does not have a cell phone or if you choose to not provide us with the number, simply click NO, here.

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name *

First Last

Parent/Guardian Email *

Parent/Guardian Cell Phone *

### - ### - ####

Additional Parent/Guardian Name

First Last

Additional Parent/Guardian Email

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

MEDICAL INFORMATION

The following information is required for use in case of medical emergency only.

List any allergies or drug sensitivities: *

Name of Health Insurance Carrier: *

Insurance Group #: *

List any medical conditions or physical/developmental disabilities that we should be aware of:

Additional Information

Publicity Permission:

Please indicate if you would allow pictures of this participant to be used for Bethel publicity purposes on our website, local newspapers, etc. *

Yes, I allow pictures to be used for publicity

No, I DO NOT allow pictures to be used for publicity

Name of person completing this form: *

First Last

Please indicate if you are interested in volunteering in any of the following areas:

Sunday School Teacher

Choir Parent

Youth Leader/Volunteer

Have you taken the Safe Sanctuary On-line Training within the past two years?

Yes

No

Covid Safety Protocol:

In an effort to diminish the possibility of covid transmission during Bethel activities, we will be implementing the following safety procedures:

1. Masks are not required, but you may choose to wear one at any time. However, all unvaccinated or immuno-compromised children and adults are strongly encouraged to wear a face mask (Sunday School, Youth Group, music rehearsals, etc.)
2. Hand-washing and disinfecting precautions will be observed.
3. Participants agree to NOT attend Bethel functions should they experience any covid-related symptoms OR be exposed to anyone who has contracted covid.

Music Rehearsal-specific Safety Protocol:

1. Participants may choose to wear a mask at any time but are not required to. However, those who are unvaccinated or are immuno-compromised are encouraged to wear a mask or refrain from participating in choral ensembles.
2. Children’s choirs will meet for no more than 45 minutes at a time. Adult choir rehearsals may be reduced to 50 minutes should the need arise.
3. A commercial-grade HEPA filtration system will be used to circulate and clean the air in the music room and a 30 minute break between rehearsals will allow time for the air to be circulated properly.
4. Hand-washing and disinfecting precautions will be observed.
5. We will be prepared to alter or suspend rehearsals should it become necessary.
6. Participants agree to not attend rehearsals/worship services if they show any signs or symptoms of covid OR if they have been exposed to someone who has contracted covid.
8. Should a participant contract covid after having attended a rehearsal or worship service, they agree to make Joyce Mentzer aware of it so that anyone exposed can be notified.

Signature of person completing this form: *

Clear

Please sign using either your mouse or your finger/stylus on a touch screen. By signing you affirm that you have read and agree to follow the covid safety protocol above. Thank you for your understanding and cooperation.