EPA Student Waiver Form

Student's Name

Current Age

Current Grade

Address

Date of Birth

School

Postal Code

Parent's Name

Parent's Phone

Does your student have any Physical / Emotional Needs, Allergies or Health Conditions we should be aware of?

I have read and agree to the Release and Permission Statment.View Release and Permission Statement

I have read and agree to the Covid-19 Release Statement.View Covid-19 Release Statement

Thank you for taking the time to register your student!

Elmira Pentecostal Assembly | 290 Arthur St. S, Elmira ON, N3B 3N4 | 519-669-3973 |