<p> 112 Collier Street, Barrie, Ontario L4M 1H3 Phone 705-726-1511 Fax 705-726-0774 Email – [email protected] or [email protected] </p><p>COLLIER’S KIDS VISITOR REGISTRATION FORM- 2017 FAMILY INFORMATION</p><p>Name of Parent/Guardian ______Relationship ______first name last name</p><p>Telephone (Home) ______Office ______</p><p>Email (Home)______(Office) ______</p><p>Name of Person Attending Church:______( if different from Parent) Relationship Phone:</p><p>Emergency Contact ______Name Address </p><p>______Phone Number Relationship</p><p>1. Child’s Name: ______2. Child’s Name: ______First First ______Last (if different from above) Last (if different from above)</p><p>Birth Date:______School Grade: _____ Birth Date:______School Grade: _____ dd/mm/yy dd/mm/yy</p><p>Allergies/Medical Conditions______Allergies/Medical Conditions______</p><p>______</p><p>______</p><p>PHOTO/VIDEO RELEASE</p><p>I,______,PARENT/GUARDIAN the undersigned parent/guardian AUTHORIZATION of the child/children named in this form, grant permission for said child/children, to be photographed or videotaped while participating in all activities PHOTO/VIDEO RELEASE of the Children & Youth program of Collier Kids of Collier Street United Church. I also grant permission for photos I,______,or videos to be used for church purposes. the undersigned parent/guardian of the child/children named in this form,______grant permission for said child/children, to be photographed ______or videotaped while participating in all activities Parent/Guardianof the Sunday Programs Signature for Children & Youth. I also grant permission for photosDate or videos to be used for church purposes. ______Witness (Name &1 Signature) CSUC-VisitorRegistrationForm-August Date 2017 ______Parent’s Signature Date PARENT’S/GUARDIAN’S HELP</p><p>Please tick as many as may apply to YOU!</p><p>As a parent/guardian, I would love to help as a: Sunday Story Teller ____ Sunday Door Keeper ______</p><p>Sunday Helper ____ Sunday Volunteer _____</p><p>As a parent/guardian, I would love to help with: Purchasing of supplies for weekly or special occasions____ </p><p>Collier’s Kids during the Week___ Youth Program _____ Clean up during the Week____ </p><p>Extra pair of hands when needed____ Share a special talent on occasion______(name talent) Telephoning____ Driving____</p><p>As a parent/guardian, I suggest, the following to improve Collier’s Kids program.</p><p>______</p><p>______</p><p>______</p><p>_____ </p><p>Thank YOU! </p><p>OFFICE USE ONLY</p><p>APPLICATION RECEIVED: ______(NAME) (DATE)</p><p>APPLICATION INFORMATION PLACED IN DATABASE: ______ZONE #______</p><p>COLLIER’S KIDS ASSIGNED:</p><p>*GROUP NAME TAG WELCOME MAILING</p><p>2 CSUC-VisitorRegistrationForm-August 2017</p>