Waiver and medical Release | Sudbury United Pentecostal Church

Waiver and Medical Release

For overnight events involving children and youth, we require this form to be completed by the parent/guardian of all minors who are attending.

Name (Required)

Email Address (Required)

Waiver & Medical Release Form

Name of Child/Youth: (Required)

Birthday (Required)

Date: (Required)

Start date of the event this waiver covers

Emergency Contact, Phone Number (Required)

In the event of an emergency, who do we contact? Phone number?

Your Address (Required)

Allergies or Medical Info (Required)

Is your child bringing any medication with them? (Required)

If yes, please explain:

Does your child have any physical, mental or behavioural concerns or limitations our staff should be aware of? (Required)

If yes, please explain:

Check of your child currently, or in the last three months, has had any of the following:

Appendicitis

Asthma

Bedwetting

Chicken Pox

Covid 19

Diabetes

Ear Infection

Epilepsy

Fainting

Hay Fever

Hepatitis

Measles (German)

Measles (Red)

Mumps

Severe Stomach Ache

Sinusitis

Tonsilitis

Other

If other, explain:

Date of last Tetanus shot:

Waiver of Liability Statement

Precautions are taken for the health and safety of your child, but in the event of accident or sickness, Sudbury United 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. In case of surgical emergency, I hereby give permission to the attending physician 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 health insurance.

Provincial Health Insurance Number:

Name of Family Physician:

Physician's Phone #

By typing my name below, I acknowledge the above, and that I am the parent/legal guardian of the child named on this form, and this counts as my signature: (Required)

Signed: (Required)

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Sudbury United Pentecostal Church

2080 Lasalle Blvd. Sudbury, ON
P3A 5P5

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