G.E.M.S. Registration Form


Participant Name(required)

Family Name(required)



Your active Email (required)

Parent/Guardian Name1:
Parent/Guardian Name2:

Cell number for emergency:

Alternative emergency contact: tel#:

Who is authorized to pickup child?

Health Card #

Special Health Concerns (allergies/medications/conditions):

any special needs?

Authorizations: Can we use photos of your child in church/G.E.M.S. related print/presentations? Uploads to the church website?YesNo other:

Basic Permissions: As parent or guardian I hereby grant the right for the G.E.M.S. club
to take my child on local outings (pre-set, pre-advertised, and church office notified in
advance) with proper leader/adult care. This would consist of basic hikes or participation
in a local program on a group basis.YesNo other:

$35.00 for one
$50.00 for two
$60.00 for three

we ask that you do this simple math question to prove this is being submitted by a person :

© 2012 - 2019 Living Hope Christian Reformed Church,
All right reserved.
1 Consumers Place, Peterborough, Ontario K9L 0C5
Tel.: (705) 740-9293, Fax: (705) 740-9994, Email: office@livinghope.on.ca
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