JR High Registration Form Sept 2026- June 2027 • Bethel Pentecostal Church

Information received is confidential and is being gathered for the purposes of serving your child while in the care of Bethel Pentecostal Church. Any medical information collected here serves to authorize Bethel Pentecostal Church, and its staff and volunteers, to obtain medical assistance in emergencies.

Activity: Bethel Youth

Date: Weekly Jr. High Night at Bethel Pentecostal Church September 2026 - June 2027

Leaders: Pastor Jody Baillie, Lacy Cameron, Pastor Kerby Stivene

Student Info

Students First Name *

Last Name *

Date of Birth *

Gender *

Grade *

School

Home Address *

Parent/Guardian Info

Parent/Guardian Name(s) *

Parent/Guardian Phone Number *

Parent Email Address *

Emergency Contact

Emergency Contact Name and Number *

Relationship to Student *

Pick-Up/Transportation

At the end of JR High, the student may leave: *

With Parent/Guardian Only

With Approved adult(s) listed below

Approved Adult(s): *

Medical/Safety Information

Allergies *

Does your student have any life threatening allergies? *

Yes

If yes, please list

Is your child bringing any medication with him or her? (Antibiotics, ventolin, ritalin) *

Yes

Does your child have any physical, emotional, mental or behavioural concerns or limitations that our staff should be aware of? *

Yes

The safety of your child is our primary concern. Precautions are taken for the safety and health of your child. In the event that your child requires special medication, x-rays or treatment, the parents/guardians will be notified immediately.

I/we, the parents or guardians named above, authorize Pastor Jody or one of the Bethel Pentecostal Church Ministry Staff to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment treatment or procedures for the participant named above.

I/we named above, undertake and agree to indemnify and hold blameless the Pastor, the Ministry Staff, Bethel Pentecostal Church, its Pastors and Church Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the Bethel Pentecostal Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to events of the Bethel Pentecostal Church. In the event that your child requires special medication, x-rays or treatment, the parents/guardians will be notified immediately.

I have read and agree with the above three paragraphs *

Yes

I hereby consent to the use of an electronic signature, which shall have the same legal effect as a handwritten signature. *

Yes

Purpose and Extent

Bethel Pentecostal Church is collecting and retaining this personal information for the purpose of enrolling your child in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities at our Church. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Bethel Pentecostal Church to limit the information collected, or to view your childs information, please contact us.

BETHEL JR HIGH STUDENT EXPECTATIONS

Bethel JR High is committed to creating an environment where every student can belong, build healthy relationships, ask questions, grow in faith, and encounter Jesus.

To help create a safe and welcoming environment for everyone, students are expected to:

Treat others with respect — including students, leaders, volunteers, church property, and event venues.
Choose safe and healthy behaviour — bullying, harassment, threats, fighting, sexual misconduct, substance use, vaping, and other unsafe behaviour are not permitted.
Listen to leaders and follow safety expectations — students are expected to follow reasonable instructions from JR High leaders and respect activity boundaries.
Use phones and social media responsibly — never photograph, record, or post another student in a way that is humiliating, private, inappropriate, or unsafe.
Help create a place where everyone belongs — include others, encourage one another, and help make JR High a place where students feel known, valued, and safe.

Media Release * Optional***

I, the undersigned, hereby consent to the use of my students photograph or likeness in any publication, videotape, pamphlet or promotion by Bethel Pentecostal Church or other agencies which are promoting or furthering the mission of Bethel Pentecostal Church. I understand that I will not receive separate compensation or consideration from Bethel Pentecostal Church or anyone else for the permission granted in this Consent nor for the actual publication or use of my students photograph or likeness. By signing this Consent, I understand I am releasing Bethel Pentecostal Church from any and all liability that may occur as a direct or indirect result of my students photograph, the release of my identity, or the public relations materials, including but not limited to the use of any quotations.

I agree to the media release *

Yes