Adventurers Medical Information and Liability Release Record
Crusaders Adventurers Ministry (2023-2024)
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Parent/Guardian and Emergency Contact Information:
In the following section, please list the parent’s/legal guardian’s name and contact information as well as an additional emergency contact person. The additional person will be notified if the parent(s)/guardian(s) cannot be reached.
Adventurer's Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Home phone number *
City *
Province *
Daytime phone/cell number *
Secondary Contact Person *
Relationship to Adventurer *
Daytime/Cell phone number *
Adventurer’s Health Record and Medical Information:
The Ontario Conference of Seventh-day Adventists is required by law to obtain the following health information before accepting an Adventurer participant. Please bring a copy of immunization record with registration fee.
Adventurer Physician *
Office Phone number *
Health Card number *
History *
Required
Allergies *
Required
Antidote
Medication: is the child currently taking any medication? *
Required
Drug name
Dosage
Time
Time
:
Permission to administer Tylenol
Permission to administer Asprin
I am/We are in favour of the aforementioned child attending Adventurer events (i.e., fun days, fairs, rallies, field trips, club meetings, camporee, etc.) and participating in all activities unless otherwise specified. As parent(s)/legal guardian(s), I/We accept the conditions stated, including the release of the Ontario Conference of Seventh-day Adventists from liability in case of accident or illness. I/We support, and the applicant agrees to abide by all event rules and Adventurer regulations and polices. In case of emergency, I/we give permission to the nurse/adult leader selected by the Adventurer Council/Club to hospitalize, secure proper treatment for, and to order injections, anaesthesia, or surgery for my/our child. If the child’s medical information changes after initial submission, please notify the Ontario Conference Adventurer Department and your child’s Adventurer Club in writing. *
Parent/legal guardian
Date
MM
/
DD
/
YYYY
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