waiver & medical release form 2018/19

Youth Friday Nights, Off-Site & Small Group Activities

Name Of Youth *
Name Of Youth
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Does you child have any allergies? (bee stings, food, penicillin, other drugs) *
Is your child bringing any medication with him or her? *
If yes, please specify
Does you child have any physical, emotional, mental or behavioural concerns or limitations that our staff should be aware of?

At youth events we take pictures to remember events and share the excitement of youth group with others. We may take pictures of you child and use them on the youth web site or in another form of promotional material (e.g brochure, Facebook, etc.) Unless submitted in writing to the church we will assume this is permissible. 

Precautions are taken for the safety and health of you child, but in the event of accident or sickness, Ellerslie Road Baptist Church, its staff, its volunteers are hereby released from any liability.

In the event that you child requires special medication, x-rays or treatment, the parents/ guardians will be notified immediately. 

In case of surgical emergency, I hereby give permissions to the physician selected by Ellerslie Road Baptist Church to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. 

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