PLEASE PRINT & COMPLETE THIS FORM, ONE FOR EACH CHILD
Ajax Alliance Church - Vacation Bible School - August 2017
REGISTRATION DAY IS JULY 15, 10 TO 4 PM, during the family fun FESTIVAL

Child’s  Name:  _____________________________________________________________________
 
Photos
Please sign below to grant your permission for the reasonable use of photos containing your child in any of the following ways: brochures/promo material; website; church; newsletters.

Signature__________________________________

Medical Information
Information received is confidential and is being gathered for the purposes of serving your child while in the care of Ajax Alliance Church. Any medical information collected here serves to authorize Ajax Alliance Church staff and volunteers to obtain medical assistance in emergencies.

Health Card No.: ___________________________________________________________

Family Doctor:_____________________________________________________________

Phone No.: _______________________________________________________________

PLEASE INCLUDE RESPONSES TO QUESTIONS BELOW, AS APPLICABLE, regarding any special information of which the staff should be aware: (e.g. health needs, allergies, medications, physical limitation)

I/we, the parents or guardians named below, authorize Pastor Randy Mann or one of the Ajax Alliance Church Ministry staff to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the named participant(s).
I/we undertake and agree to indemnify and hold blameless the Pastor, ministry staff, Ajax Alliance Church, its members and board of elders from and against any loss, damage or injury suffered by the participant(s) as a result of being part of the activities of Ajax Alliance Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in Ajax Alliance Church summer day camp 2016.

Signature of parent/guardian:

(sign here)___________________________________
 
 
Name (PRINT PLEASE) of parent/guardian:

(print here)___________________________________
 
 
SPECIAL HEALTH NEEDS? _______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

ANY ALLERGIES? _______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

MEDICATIONS? _______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

PHYSICAL LIMITATIONS? _______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________
 
PRINT, FILL OUT AND BRING THIS FORM TO REGISTRATION DAY BETWEEN 10 AND 4 ON JULY 15 AT AJAX ALLIANCE CHURCH, 515 RITCHIE AVE. IN AJAX (WESTNEY AND THE 401).
 

Copyright © 2017  Ajax Alliance Church • Ajax, On • 905-427-6613