Innisfil Community Church / Programs / Summer Day Camps

Program Registration - Waiver and Medical Release

This form is for our day camp registrations

Ages: SK - Gr. 6

Cost (per child):

Registration Fee: $80/Wk

Dates:

July 10 - 14 - Sports Camp (FULL)

July 17 - 21 - Art Camp (FULL)

July 24 - 28 - Water Camp (FULL)

VBS - August 7 - 11 (Morning program, FREE)

To register your child, fill out form and submit online.

Payment can NOT be received online.

Payable by Credit Card, Debit, Cheque or Cash. (At the church not online)

Make all cheques payable to Innisfil Community Church MEMO: DAY CAMP

PLEASE NOTE: YOUR SPOT IS NOT RESERVED UNTIL PAYMENT HAS BEEN MADE.

Child's Full Name

Grade

Date of Birth

Address:

City:

Province

Postal Code

Health Card Number

I give my permission for my child to be released from the program on their own, without security receipt or parent pickup.

YES

Does your child have any severe allergies? (bee stings, food [i.e. peanuts, etc, penicillin, other drugs)

YES

IF YES, PLEASE EXPLAIN:

Does your child have any life-threatening allergies?

YES

IF YES, PLEASE EXPLAIN:

Is your child bringing any medication with him or her? (Antibiotics, ventilator, Ritalin)

YES

IF YES, PLEASE EXPLAIN

Does your child have any physical, emotional, mental or behavioural concerns or limitations that our staff should be aware of?

YES

IF YES, PLEASE EXPLAIN

Has your child currently, or within the last three months, had any of the following:

Asthma

Epilepsy

Diabetes

Fainting

Date of last Tetanus shot, if known:

Any other details or concerns, please enter them below:

DISCLAIMER OF LIABILITY, RELEASE OF CLAIMS, & MEDICAL RELEASE - IMPORTANT PLEADSE READ CAREFULLY

By signing below I understand and give informed consent for my child to participate in any or all of the programs and activities offered by Innisfil

Community Church including periodic events and activities that are held off premises from time to time.

Medical Release: I (we) also understand, precautions are taken for the safety and health of your child, but in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached I give my permission to a licensed medical practitioner to provide the care necessary, special medication, x-rays or treatment, including anaesthesia, for my child’s well-being. In the event of accident or sickness, Innisfil Community Church, its staff, and its volunteers are hereby released from any liability.

In case of surgical emergency, I hereby give permissions to the

physician selected by Innisfil Community Church to hospitalize, secure proper treatment for, and to order injection, anaesthesia or surgery for my child as named above. (Your child must be covered by Provincial Health Insurance or equivalent medical insurance.)

This Disclaimer of Liability and Release of Claims is to be executed by the participant, or if the participant is a minor, by the participant’s parent/guardian.

The Application for Program Registrations (“Application”) will not be accepted unless it has been executed. In consideration of the Innisfil Community Church accepting this Application I agree to this disclaimer r of Liability and Release of Claims.

Disclaimer: The participant assumes all risks associated with his or her participation in the programs offered by Innisfil Community Church. Innisfil Community Church accepts no liability for bodily injury, death, property or loss due to any cause whatsoever, including, without limitation, negligence on the part of the Innisfil Community Church, including its elected officials, employees, agents and volunteers.

Release: The participant and his or her parents/guardians waive any and all claims they may now and in the future may have against, and release from all liability and agree not to sue, the Innisfil Community Church and its elected officials, employees, agents and volunteers. This release includes all claims for bodily injury, death, property or loss sustained by the participant as a result of his or her participation in the programs and activities offered by Innisfil Community Church including, without limitation, negligence on the part of the Innisfil Community Church, its elected officials, employees, agents and volunteers. I hereby give permission for Innisfil Community Church staff to take photographs of my child, children or myself. I understand that the photographs may appear in the Innisfil Community Church newsletters, promotions and/or Innisfil Community Church web site.

I confirm that I have read this agreement before signing it and that I understand it and that it is binding not only on me and the participant but also on our helps, executors and assigns. This application will not be accepted unless signed. Consent extends beyond the current year, and remains until withdrawn in writing to the church

BY CLICKING "I AGREE" YOU AGREE TO ALL OF THE ABOVE

I AGREE

DISAGREE

Parent's Full Name:

Phone Number (Home)

Phone Number (Work)

Phone Number (Cell)

Emergency Contact (other than parent)

Emergency Contact Phone Number

Name of Family Physician

Family Physician's Phone Number

Would you like more information about Innisfil Community Church? (Our kids and youth programs, life groups, small groups for adults, sunday services etc.)

YES

Event Registration