*be at the church

for 8:45am

CHAPERONES - Ben Albrecht, Carli Albrecht...

Name of Child: _________________________________________ Age:

Emergency Phone: ________________________________________

Alternate emergency contact: _______________________________

Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Parkway Road Pentecostal Church, its staff, and its 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.

Parent/Guardian’s Name (Please print): ___________________________ Date:

Parent/Guardian’s Signature _________________________________________

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If your child has never before submitted a waiver to our church for an event, or you have updated information to make us aware of, please take a moment to provide us with the following information:

Does your child have any severe allergies? (bee stings, food, penicillin, other drugs) Y_____N _____If yes, please explain: ________________________________________________________________

Does your child have any life-threatening allergies? Y _____________ N____________If yes, please explain: ________________________________________________________________

Is your child bringing any medication with him/her? (Antibiotics, Epi-Pen, Ritalin, ventilator)Y_ N_If yes, please explain: _________________________________________________________________

Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of? Y _____________ N _____________If yes, please explain: _________________________________________________________________

Your child must be covered by Provincial Health Insurance or equivalent medical insurance. Provincial Health Insurance Number: ____________________________________________________

Name of Family Physician:_____________________ Physician’s Phone Number: _________________Notes:

MOSAIC STUDENT MOVEMENT [WAIVER & MEDICAL RELEASE FORM]

CALYPSO WATERPARK 2014THURSDAY JULY 10TH // 9AM-6PM

Children’s/Youth Ministries, Parkway Road Pentecostal Church,

7275 Parkway Road, Box 250, Greely, Ontario, K4P 1N5Phone: 613-821-1056 Fax: 613-821-0026