CONSENT FOR & MEDICAL RELEASE: - DCC’s Summer Day Camp 2014-

Appendix 6A
Page 1 of 2
CONSENT FOR & MEDICAL RELEASE:
- DCC’s Summer Day Camp 2014Both sides of this form must be completed, signed and returned to Dresden Community Church on or before
June 30th in order for your child to participate in this event, provided it is not FULL prior to.
Dresden Community Church, Box 1078, Dresden, Ontario N0P 1M0
All information collected is CONFIDENTIAL and for the sole purpose of Dresden Community Church. It will not be shared with third parties.
Only persons with legitimate need will have access to any information obtained.
I give my child permission to participate in the following:
Activity:
Location & Phone:
Date:
Dresden Day Camp
Dresden Community Church
29043 Community Road, Dresden, Ont 519-683-6541
Monday July 7 through Friday July 11, 2014
9:00 am to 4:00 pm each day
(Thursday camp begins at 10:00 am)
Name of Child:
Date of Birth: dd/mm/yyyy
911 Address:
Age:
Box or RR #:
Postal Code:
Sex:
Parents/Step-parents/Guardians:
Contact phone:
E-mail address:
School:
Entering grade (Sept ‘14):
PARENTS PLEASE READ AND SIGN:
We will be: participating in various indoor and outdoor events during Day Camp including crafts, water
games, sing songs, chapel and other activities. Students will be supervised by: approved volunteers of
Dresden Community Church, Rev Colin Paterson, and Pastor Chris Quiring and other approved
leaders/assistants from D.C.C. will help with supervision throughout the week.
Knowing that the adult sponsors will take utmost care of my child's safety, I understand that accidents do occur
and that in such situations, immediate steps must be taken to secure my child's health. I hereby authorize the staff
and/or adult volunteer leaders in charge of the program to seek medical attention for my child should an
emergency arise, provided that I am contacted as soon as possible. Failure to reach me shall not prevent an
application of immediate necessary medical treatment, not excluding injection, anesthesia or surgery.
I further agree that Dresden Community Church shall be held harmless in the event of accident or injury, and in
that regard, I understand that Dresden Community Church disclaims any and all liability in the unlikely event of
injuries sustained in connection with this event.
I DO NOT give permission for any pictures taken through the course of normal activities to be
published.
I DO NOT give permission for my family to be contacted by e-mail at the address(es) given.
Signature of parent or guardian:
Date:
Appendix 6A
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Allergies/medications/medical concerns:
Does you child have any severe allergies? (bee stings, food, penicillin, other drugs)
YES
NO
YES
NO
If yes, please explain:
Does you child have any life-threatening allergies?
If yes, please explain:
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?
YES
NO
YES
NO
If yes, please explain:
Date of last Tetanus shot:
Is your child bringing any medication with him or her? (antibiotics, Ventoilin, Ritalin)
If yes, please explain:
If medication is required during this event, that medications must be released to one designated person per event when you drop
the child off. The medications will be stored in a locked container. All medication must be in the original package that states the
name of the child, name of the medication, dosage and name of the physician. Medication will be dispensed in accordance with this
consent. The designated person will watch the child take the medication. It is the responsibility of the family to collect the medication
at the end of the event.
Epi-pens and inhalers are the exception and may be carried by the person requiring them.
Name of child:
Name of medication:
Dosage to be taken:
Time to take the medication:
Signature of parent or guardian:
Date:
Your child must be covered by Provincial Health Insurance or equivalent medical insurance.
Provincial Health Insurance Number
Name of Family Physician
Physician's Phone Number
If you feel that there may be custodial issues over this child, child, please make the staff or volunteers of DCC aware, so that the child may be
released only to the custodial parent.
You may release my child to any of the following individuals:
Or
My child may be transported home by any of the following individuals:
1.
2.
3.
****PLEASE BE AWARE that SPACE IS LIMITED and registration will be taken on a FIRST COME, FIRST
SERVED BASIS. PRE-REGISTRATION IS REQUIRED.
**In the event of last minute cancellations, those on the WAITING LIST will be given first priority.