OFFICE USE ONLY: GROUP: COLOR: PAID: $____________ Broadway Church Children’s Ministry Waiver and Medical Release Form for Special Events Activity: ForeverLand VBS Kids Camp Dates: Monday, July 27th to Friday July 31st 2015 at Broadway Church Time: 9am-1pm For children ages 4-12 Cost: $60 (includes all activities, lunch, and t-shirt) Name of Child: _____________________________________________ Age:________________ Birthday: Day_________ Month:_________ Year: _________ Male:_____ Female:_____ Address:__________________________________________________ Postal Code:_________ Name of Parent/Guardian:______________________________ Phone:__________________ Email Address: __________________________________________________________ Friend Request: (is there someone you know coming to VBS you would like to be in the same group with?)________________________________________________________________________ T-shirt size (circle one) Youth: S M L XL Adult: S M L Does your child have any severe/life threatening allergies? (Bee sting, food, penicillin, other)? YES____ NO____ If yes, please explain:_____________________________________________ ______________________________________________________________________________ _________________________________________________________________ Is your child bringing any medication with him/her? (Antibiotics, ventilator, Ritalin) YES___NO___ If yes, please explain:_______________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________________________________________ (turn page over for more information --) 1 Does your child have any physical, emotional, mental or behavioral concerns that our staff should be aware of? YES____ NO___ If yes, please explain:______________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _________________________________________________________________________ ***Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Broadway Church, its staff, and volunteers are hereby released from any liability. In the event that your child requires special medication, x-rays or treatment, the parents/guardians will be notified immediately.*** Your child MUST BE covered by Provincial Health Insurance or equivalent medical insurance. Care Card Number: ______________________________________ Name of Family Physician:________________________ Physician’s Phone #:_______________ Emergency Contact: (in case we can’t reach Parent/Guardian) Name:________________________ Relationship:_____________ Phone#:________________ I/we the undersigned parent(s) or legal guardian(s) of the child listed above, declare that I/we voluntarily assume all risk or personal injury, loss of property, damage which may arise from participation in or attendance at these functions, including travel to and/from these functions, whether such injury, loss, or damage shall arise from negligence or otherwise. Broadway Church Children’s Ministries upholds the standard that children respect the rights and property of others. If this behavior cannot be maintained, the organization reserves the rights to withdraw the child from the program or withhold the right to participate in future events. Parent/Guardian Signature:_____________________________________ Date:____________ 2