Fellowship Bible Church + Baden Central Church

Youth Waiver & Medical Release Form

Activity: Year End Campfire and Games
Date: June 13th, 2025
Time: 7:00pm - 9:00pm
Drop Off & Pick Up: 1404 Sandhills Rd.
Person in Charge of Event: Dan Toman
Chaperones: Lynne Rutledge, Justin Frenette, Dan Toman

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