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Veith House PD Day April 2nd
Join us for a PD Day on April 2nd!

The day will run from 9:00 AM-4:30 PM. The cost is $30 a child, which includes snacks and lunch.

We'll be spending time outside, making art, and connecting with our community. 

Please fill out one form per child (children ages 5-12).

Email: ally.lord@veithhouse.ns.ca with any questions!

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Guardian Full Name
Guardian Phone: 
Child's Name:
Child's Pronouns
Child's age
Child Birthday 
Child Healthcard Number & Expiry:
Child Address (Street Address, Apartment, Postal Code, City) 
Child Allergies:
Child Health Conditions:
Secondary Contact Name: 
Secondary Contact Relationship: 
Secondary Contact Phone: 
CONSENT TO WALK HOME: I give my child permission to walk home at the end of Veith House programs. I understand that the Veith House programs are not liable for anything that happens to my child once they leave the program. I understand that my child is under care and supervision of Veith House Staff until 4 PM, and after this time, should I consent, my child is free to leave Veith House on their own. (If you plan to pick up your child at the end of the program instead, please communicate with staff.)
ASSUMPTION OF RISK: I understand the nature of the various program activities and workshop topics of discussion, that my child is qualified, in good health and in proper physical condition to participate in these activities, and that if I have any questions or concerns about my child’s health and/or ability to participate, I should consult with a physician beforehand. 
RELEASE AND WAIVER OF LIABILITY: I, for myself and for my heirs, personal representatives and assigns, do hereby release, waive, discharge, and covenant not to bring suit against Veith House, its affiliated or subsidiary companies, its officers, directors, employees, agents or representatives (whether compensated or not), its volunteers, participants, sponsors and advertisers, the owners or lessors of premises on which the activities are held, and any other party indemnified and held harmless by Veith House, each considered to be one of the “Releasees” herein, from all liability, claims, demands, losses, or damages which I suffer caused or alleged to be caused in whole or in part by the negligence of the “Releasees.”
AUDIO-VISUAL AND TESTIMONIAL RELEASE: I understand that while conducting its programs, Veith House may make photographic, video and/or audio recordings of its activities and participants, including images captured or recorded using film cameras, digital cameras, analog or digital video recorders or any other reasonably-related devices capable of capturing or recording images, video and/or audio. I grant and convey to Veith House an irrevocable and permanent right, title and interest in any such recordings, which may include my child, and to use them for any lawful purpose including derivation of economic or other benefit.
ACKNOWLEDGEMENT: I have read this Release and Waiver of Liability and Indemnification Agreement and understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature. I intend it to be a complete and unconditional release of all liability to the broadest and most comprehensive extent allowed by law, and I agree that if any portion of this Agreement is held to be invalid under the laws of my province of residence or jurisdiction in which the activities are conducted, the balance, notwithstanding, shall continue in full force and effect so as to affect the intended release, waiver and indemnification to the greatest degree possible. By signing below, I agree to all of the above agreements.
Cost is $30. Are you prepared to pay this by e-transfer, cash, or cheque? 
Signature: Thanks for reading these long questions!
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