Liberty Kids Wednesday Nights (Ages 6 -12)

Name

Birthday (DD-MM-YYYY)

Age

Address

Gender

Male Female

Allergies/Medical Conditions

Authorized Individuals for Child Pick-Up

Participant Support & Safety Needs

Should your child require 1:1 assistance please provide the name of the child care worker

Special needs (behavioural / emotional / physical)?

If Yes, specify special need

Consent/Waiver

As the parent and/or legal guardian of the child listed on this form, I/we authorize emergency medical treatment under the direction of a licensed physician or qualified medical professional in the event of a medical emergency where delaying treatment could reasonably place the child’s health or well-being at risk. This authorization will be used only after reasonable efforts have been made to contact the parent(s) or guardian(s) using the contact information provided on this form. I/we understand and accept responsibility for any costs associated with such medical treatment. I/we give permission for the child listed on this form to participate in Liberty Kids Wednesday Nights at Liberty Pentecostal Church Bowmanville. I/we understand that participation in Liberty Kids Wednesday Nights may include games, activities, recreation, crafts, lessons, and other age-appropriate programming. While reasonable precautions will be taken to provide a safe environment, I/we acknowledge that participation in these activities may involve unforeseen risks or hazards. By providing consent, I/we acknowledge these risks and agree not to hold Liberty Pentecostal Church Bowmanville, its pastors, staff, leaders, volunteers, or assistants responsible for injury, loss, or damages arising from participation in Liberty Kids Wednesday Nights, except where liability cannot legally be excluded. I/we confirm that the information provided on this form is accurate and that I/we have the legal authority to provide this consent on behalf of the child listed.

I give permission for my child's photos or videos to be taken and used by Liberty Online Church for promotional or media purposes, including social media, the church website, newsletters, and other communications.

Guardian/Parent Name

Phone

Address

Today's Date

Emergency Contact

First & Last Name

Phone

Relationship to Child

Liberty Kids Wednesday Nights (Ages 6 -12)

Description

Please Fix the Following