Youth summer camp waiver and registration

Registrant's Name*

First NameLast Name

Name of the Parent/Guardian*

First NameLast Name

Registrant's age*

Parent/Guardian's Phone Number*

Parent/Guardian's Email*

example@example.com

Registrant's Phone Number (if applicable, just so we are able to contact you during the retreat)

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How many nights will your child be staying?*

1 night (Aug 22-23)1 night (Aug 23-24)2 nights (Aug 22-24)

Does your child need transportation?*

YesNo, my child has a driverNo, I will be drivingOther

Does your child have any severe/life-threatening allergies? (if so, please list allergies in the next question)*

YesNo

List your child's allergies. *

Is your child bringing any medication? (if so, please list the type of medication they will be bringing in the next question)*

YesNo

List the type of medication *

Provincial Insurance Health Number*

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

Name of Family Physician*

Physician's Phone

Liability Release and Parental Consent

In order for my child to participate in the Maple Baptist Church, Youth Retreat program at Silverlake Wesleyan Camp, I hereby waive, release, and discharge any and all claims for damages for personal injury, and property damages or which may hereafter occur to me as a result of participation in said event.

This release is intended to discharge in advance the Maple Baptist Church, its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees.

I hereby give my consent to have the above applicant treated by emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the above activity. It is understood that Maple Baptist Church and Silverlake Wesleyan Camp will provide no medical insurance for such treatment, and that the cost thereof will be at my expense.

I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions.

How will you be paying? COST: $100*

E-transfer to janaya.queddeng@gmail.comCash

Signature to consent

Youth Summer Camp