QBC Children & Youth Ministries 2021-2022 Registration

If you have any problems with this form, please contact us.

* indicates required field

Parent Information

Parent/Guardian 1

First Name:
Last Name:
Cell Phone:

Parent/Guardian 2

First Name:
Last Name:
Cell Phone:


Address Line 1:
Address Line 2:
Postal Code:
Home Phone:

Child Information

You may add additional children by clicking "+ Add Child".

Child 0

First Name:
Last Name:
Gender: M     F
Grade (as of Sept. 2021):
Health Card #:
Medical/Mental Health Conditions:
Anything else we should know about this child?:
Self release: Check this box if this child is authorized to release themselves into their own care:

Emergency Contact Other Than Parents

First Name:
Last Name:
Home Phone:
Cell Phone:
Relationship to the Children:

Pickup & Drop-Off

Authorized People

People (other than parents) authorized to pick up and drop off children:

Special Instructions

Special instructions for drop-off/pickup:

Photo & Video Usage

From time to time, QBC may wish to use photos and videos of your children without identifying information on photo slide shows, bulletin boards, flyers, the QBC website, etc. We do this to give a personal touch to our communication and to celebrate what God is doing in our ministry. Note: We reserve the right to use photos without permission where your children are not distinguishable, such as photos in which they are part of a group.

Yes, QBC may use photos/videos of my/our children without identifying information
No, QBC may not use photos/videos of my/our children