General annual 2024-2025 St Pauls waiver form

General annual Off-Site Activity Program Waiver and Medical Release

Pioneers of Paul (POP) volunteer activities taking place away from St. Paul's Anglican Church building and property.

Sept 1, 2024 - June 30, 2024

First Name (youth)

Last Name (youth)

Birth date

Date

Full Address

Parent/guardian/caregiver name

Phone number where parent/guardian may be reached when trip is taking place.

Cell phone

Does the participant have any severe allergies or other medical condition that leaders should be aware of? Yes No

If yes please list and explain

All reasonable precautions for the safety and health of the participant will be taken. They will be properly supervised in activities. In the event of accident or sickness, St. Paul's Anglican Church, its staff and volunteers are released from any liability. In the event of injury requiring medical attention, I authorize treatment for the participant and understand that reasonable attempts will be made to contact me, should such a situation occur. In the event that travel or activities take place outside this province, I understand that any medical costs incurred by the participant are my responsibility. The participant must be covered by provincial health insurance or equivalent medical coverage.

Alberta Health Care Insurance number

Participant's Family Physician

Family Physician's Phone Number

Contact person (not parent) in case of emergency and parents / guardians / caregivers cannot be reached:

Contact Name

Phone

Contact Name

Phone

ParentGuardian Signature

ParentGuardian Name PRINT