Chatham Ringette Association

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2019-2020

Medical Waiver Form

Name *

Birth Date *

YYYY

Address *

City *

Postal Code *

Parent(s) / Guardian(s) *

Home phone *

Cell phone *

Emergency contact

If we are unable to reach parent/guardian in an emergency, who should we call?

Name *

Phone number *

Medical Information

Please check the appropriate responses pertaining to your child *

Yes

Diabetes

Epiletic

Asthma

Has had a concussion

Food or Drug Allergies

Details for food or drug allergies

If applicable

Details for concussion

If applicable

Please indicate any other medical information you feel the association should be aware of.

Photo release

Chatham Ringette Association requests your permission to use pictures taken of your child on our website and/or in future Chatham Ringette promotional materials. *

YES - Photographs of my child may be used on the CRA website and/or CRA promotional materials.

NO - Do not take any pictures of my child.

Consent

Chatham Ringette Association will provide every safeguard for the health and welfare of each participant and staff member but will not be held responsible for injury, sickness and/or accidents. In the event of an emergency and/or special medical treatment, parents or their designates will be notified immediately. If the parents/designates cannot be reached, permission is hereby granted to Chatham Ringette Association to take whatever steps deemed necessary to ensure the safety and health of participants and staff members.

I understand and accept these conditions.

I do not accept these conditions

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