Waiver Form: SUMMERVBS2015

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
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 --)
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
Parent/Guardian Signature:_____________________________________ Date:____________