EPIC Jr. High in House Retreat
WAIVER & MEDICAL RELEASE FORM
Feb 22nd-23rd 2019
Costs: $85
DEADLINE: Feb 20th
Activity: Retreat @ Bethel Pentecostal Church
Date: Feb 22nd & 23rd
Times: Friday- Reg. 7pm
Pick up Sat. 4pm
Chaperons: Pastor Mitch Pitt and the Jr High Leadership Team
Name of Child *
Your answer
Age: *
Your answer
Address *
Your answer
PC *
Your answer
Phone *
Your answer
School *
Your answer
Does your child have allergies
Please explain the allergy *
Your answer
Does your child have a life threatening allergy? *
Required
Please explain the life threatening allergy *
Your answer
Is your child bringing any drugs with them? (antibiotics, ritalin , ventilator)
Your answer
Does your child have emotional, behavioural, mental concerns or limitation that the staff should be aware of? *
Your answer
Check if your child currently, or within the past three months has had any of the following:
Date of Last Tetanus Shot? *
MM
/
DD
/
YYYY
Pre-cautions are taken for the safety and health of your child but in the event of an accident or sickness, Bethel Pentecostal Church, its staff and volunteers are hereby released of any liability.
In the event your child needs special medication, x-rays or treatment, the parents/guardian will be notified immediately.
In case of surgical emergency, I hereby give my permission for a physician selected by Bethel Pentecostal Church to hospitalize, secure proper treatment, and to order injection, anesthesia, or surgery as named above. (your name below will serve as an electronic signature) *
Your answer
Your child must be covered by Provincial Medical Insurance or an equivalent medical insurance.
*** Provincial Health Insurance Number *** *
Your answer
Name of Family Physican *
Your answer
Physician's Phone Number *
Your answer
Signature of Parent or Guardian (if under 18) (your name below will serve as an electronic signature) *
Your answer
Pastor Mitch Pitt - Student Ministries Bethel Pentecostal Church 500 Viewmount Drive Nepean ON K2E 7P2 Phone - 613.816.1383 Email - mpitt@bethel.ca
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