Kids PD Day Camp Registration Form
Student Name *
Your answer
Date of Birth (month/day/year) *
Your answer
Grade In School *
Your answer
Parents/Guardians Names *
Your answer
Address *
Your answer
Phone Number *
Your answer
Alternate Phone Number
Your answer
Email
Your answer
Family Doctor *
Your answer
Doctor's Phone Number *
Your answer
Allergies and Treatment *
Your answer
Does your child have any physical, emotional, behavioural concerns or limitations that our staff should be aware of? *
Your answer
Is your child bringing any medications with him/her? *
Required
If yes, please list. Please note that Community Bible Church staff and volunteers are not permitted to administer any medication, with the exception of epi-pens and puffers.
Your answer
I/We the parents or guardians named above, authorize a Community Bible Church staff or volunteer to sign a consent for medical treatment and to authorize a physician or hospital to provide medical assessment, treatment or procedures for the participant named above in the event that I cannot be reached. *
Parent/Guardian Signature
Your answer
*
Date
Your answer
I/We, named above, undertake and agree to indemnify and hold blameless the Ministry Staff, Community Bible Church, its Pastors and Board of Elders from and against any loss, damage or injury suffered by the participant as a result of being part of the Kids PD Day Camp, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in the Kids PD Day Camp at Community Bible Church *
Parent/Guardian Signature
Your answer
Date (month/day/year) *
Your answer
Submit
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