EPIC Jr. High in House Retreat
WAIVER & MEDICAL RELEASE FORM
Feb 22nd-23rd 2019
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
Does your child have allergies
Please explain the allergy
Does your child have a life threatening allergy?
Please explain the life threatening allergy
Is your child bringing any drugs with them? (antibiotics, ritalin , ventilator)
Does your child have emotional, behavioural, mental concerns or limitation that the staff should be aware of?
Check if your child currently, or within the past three months has had any of the following:
Severe Stomach Ache
Date of Last Tetanus Shot?
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 child must be covered by Provincial Medical Insurance or an equivalent medical insurance.
*** Provincial Health Insurance Number ***
Name of Family Physican
Physician's Phone Number
Signature of Parent or Guardian (if under 18) (your name below will serve as an electronic signature)
Pastor Mitch Pitt - Student Ministries Bethel Pentecostal Church 500 Viewmount Drive Nepean ON K2E 7P2 Phone - 613.816.1383 Email -
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