Fellowship Bible Church + Baden Central Church - Progressive Dinner Form March 22nd

Youth Waiver & Medical Release Form

Activity: Progressive Dinner (hosted at the Symons, Katherine Gerber's, and Lamberts).
Date: March 22nd 5:45pm
Person in Charge of Event: Kai Johnson & Lynne Rutledge
Chaperones: Kai Johnson, Lynne Rutledge

Name of Child or Youth:

Address:

Postal Code:

Age:

Cell/Home Number:

Emergency Contact's Name:

Emergency Contact's Phone Number:

Emergency Contact's Relationship with Child:

Does your child have any severe allergies (bee stings, food, penicillin, other drugs)?

Yes

No

If yes, please explain:

Does your child have any life-threatening allergies?

Yes

No

If yes, please explain:

Is your child bringing any medication with him or her (antibiotics, ventilator, Ritalin, Episode-Pen)?

Yes

No

If yes, please explain:

Does your child have any physical, emotional, mental or behavioural concerns or limitations that our staff should be aware of?

Yes

No

If yes, please explain:

Provincial Health Insurance or equivalent medical insurance must cover your child.

Health Card Number:

Family Physician:

Family Physician's Phone Number:

Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Fellowship Bible Church, its staff, and its volunteers are hereby released from any liability. In the event that your child requires special medication, x-rays or treatment, the parents/guardians will be notified immediately.

Signature

Date of Signature