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 2021) *

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. Physical distancing of three or more feet will be used for all rehearsals and performances when possible, which may mean that ensembles will sing instead of the entire group, depending on CDC guidance.
4. 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.
5. Hand-washing and disinfecting precautions will be observed.
6. We will be prepared to alter or suspend rehearsals should it become necessary.
7. 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.