Full name of participant *

First Name

Last Name

Name of Guardian/Parent *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Family Physician *

First Name

Last Name

Family Physician Phone *

(###)

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Emergency Contact #1 *

First Name

Last Name

Emergency Contact #1 Phone *

(###)

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Emergency Contact #2 *

First Name

Last Name

Emergency Contact #2 Phone *

(###)

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In the event of accident or sickness, I hereby release St. Andrew's Presbyterian Church in Ottawa, its staff and volunteers, from any liability, claims and causes of action by reason of any injury which may be sustained as a result of Church Youth Group activities, whether on Church premises, or not *

First Name

Last Name

In the event of an emergency or injury requiring medical attention, Iauthorise treatment for the participant. I understand that reasonable attempts will be made to contact me, should such a situation occur. In the event when I cannot be reached, I give St. Andrew’s Presbyterian Church staff and/or volunteers permission to seek medical attention for my child. If the above designated physician is not available or the situation warrants, I give permission to the physician, paramedic, nurse, or dentist selected by St. Andrew's Church representative to provide medical or dental aid for illness or injury including transportation to and from facilities. I agree to bear all costs associated with medical care and transportation.

First Name

Last Name

I understand that it is my responsibility to drive and accompany my child to and from this activity. If I am unable to do so, I will arrange with another parent to drive and accompany my child to and from this activity. It is my responsibility to ensure this parent’s car is prepared with an appropriate age related child car seat. If transportation is arranged by the church, I release the church from all liabilities in case of an accident.

First Name

Last Name

Date *

MM

DD

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