Child's Name (required)
Street Address (required)
Postal Code (required)
Birth Date (required)
School Grade (required)
Care Card Number (required)
Parent's Name (required)
Parent's E-mail (required)
Parent's Phone Number (required)
Emergency Contact Name (in case we can't reach you) (required)
Emergency Contact Phone Number (required)
Relationship of Emergency Contact to You (required)
Does your daughter need any of the following items ordered?
GEMS ShirtBadge Book (Gr. 4-6)Badge Display Scrapbook (Gr. 4-6)
**There is additional cost for the badge book & scrapbook if your girl(s) were already given one of these when they started the GEMS program.
I hereby release the counselor(s) from all liability not covered by their insurance on my child(ren), in case of accident or injury during meetings and group activities. This consent form authorizes designated youth leaders of Langley Canadian Reformed Church to transport my child(ren) to and from activities involved with the specified program and to take any action deemed necessary for the well-being of my child(ren). Langley Canadian Reformed Church will ensure that your child(ren) will be transported by a volunteer who holds a valid BC Driver’s License.
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21804 52 Avenue, Langley, BC Phone: (604) 530 7612
Sunday @ 9:30 AM & 2:00 PM
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