RPC Kids Camp (VBS) Registration

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Information received is confidential and is being gathered for the purposes of serving your child while in the care of Rockcliffe Pentecostal Church (RPC). Any medical information collected here serves to authorize RPC, and its staff and volunteers to obtain medical assistance in emergencies. This form is to be completed by the parent/caregiver before participating in this activity.

Shipwrecked

Please select the age appropriate week for your child *

AGES 3-6 (July 11-15, 9:00am-Noon)

AGES 7-10 (July 18-22, 1:00-4:00pm)

Required

Participant's Name *

Date of Birth *

YYYY

Address *

Phone Number *

Email Address

Health Card Number & Family Doctor Name & Number & Emergency Contact Name & Number *

Please list, if any, allergies, physical, emotional, mental behavioural limitations that staff should be aware of.

Photos: Please check yes or no, to grant permission for the reasonable use of pictures containing your child in brochures, promotional material, Rockcliffe's website, social media (Facebook, Instagram, and YouTube), Rockcliffe newsletters, and videos. *

Yes

Required

Please read the following four statements carefully. Once you have done so, please click the box next to each statement to indicate that you have read and understand and agree with each statement. *

I voluntarily agree and consent to the participation of my child in this supervised activity.

While every precaution is taken for safety and good health, some sports and activities carry with them the inherent risk of personal injury beyond the risks associated with many of the recreational activities at RPC. In understand that I am exposing my child to inherent risks and hazards. I accept all these risks and hazards and agree that by allowing my child to participate in those activities, and acknowledge that I will be responsible for any injury or other loss which may occur during my child's participation of these activities.

I, the Parent or guardian named below, authorize Pastor Phil or Pastor Michael or one of Rockcliffe Pentecostal Church's Program Personnel to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.

I, the Parent or guardian named below undertake and agree to indemnify and hold blameless Rockcliffe Pentecostal Church, its personnel, its leaders and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Rockcliffe Pentecostal Church, as well as of any medical treatment authorized by the supervising individuals representing Rockcliffe Pentecostal Church. This consent and authorization is effective only when participating in or traveling to events of Rockcliffe Pentecostal Church.

Required

Parent or Guardian Name

Date

YYYY

Submit

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