Monday nights, 6:30 to 8 PM at the Ottawa Gospel Hall, 1087 North River Rd, Ottawa
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Email *
Participant's name:  *
Age: *
Gender: *
Date of birth: *
Home address *
Parent/Guardian's name and phone number: *
Emergency Contact (Someone other than the parent/guardian, in case they cannot be reached) - Provide name and phone number : *
Does your child have any physical, social, emotional, mental or behavioral challenges that the leaders should be aware of? *
Family doctor name (if applicable): *
Health card number: *

Please indicate how your child will be picked up from UPWARDS! ART NIGHT. At the end of the activity (8:00pm ), my child will be…

The following adults are permitted to pick up my child at the end of the evening. (Please list all and indicate relationship to the child):


I/we, the parents or guardians named above, authorize UPWARDS! ART NIGHT to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above. I/we, named above, undertake and agree to indemnify and hold blameless UPWARDS! ART NIGHT, and its Directors from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of UPWARDS! ART NIGHT, as well as of any medical treatment authorized by the supervising individuals representing the camp. I/we, named above, agree that photography taken during the activities may include the image of the participant named above.  I/we, named above, understand that each session includes a time of Bible teaching.  I/we, named above, understand that food will be offered to participants during the activity.

Parent/Guardian signature (please type your name):

Date *
A copy of your responses will be emailed to the address you provided.
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