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Registracion del Participante

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All Nations Church

Location

414 St. Raphael Street

Sudbury, ON P3B 1M4

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Contact Julia Martel:

705-794-1948

jmartel@allnationschurch.ca

Primero, cuéntenos sobre usted:

Información de los Padres

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

Nombre

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Apellido

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Correo Electrónico

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Dirección 1

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Dirección 2

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Ciudad

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Estado/Provincia

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ZIP/Código Postal

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País

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Teléfono de Contacto 1

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Teléfono de Contacto 2

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Nombre del Contacto de Emergencia

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Relación del Contacto de Emergencia

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Teléfono del Contacto de Emergencia

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Cuéntanos sobre tu participante

If you child(red) is not going to be attending all 4 days or you have any concerns or questions, please email Pastor Julia directly jmartel@allnationschurch.ca

Nombre

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Apellido

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Grado Entrando

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Género

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Fecha de nacimiento

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Does your child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of?

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Please Explain

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Does your child have any allergies?

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Please explain

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Is your child bringing any mediation with them?

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Family Doctor

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Family Doctor's Phone Number?

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Health Card Number (or International Insurance Card)

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I voluntarily agree and consent to the participation of my/our child(ren) in this supervised activity. While every precaution is taken for the safety and good health, some sports and activities carry with themthe inherent risk of personal injury beyond the risks associated with many of the recreational activities at AllNations Church. I/we 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 thatI will be responsible for any injury or other loss which may occur during my child’s participation of these activities.

I/we, the Parents or guardians named below, authorize the Pastor or one of All Nations Church 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/we, named below, undertake and agree to indemnify and hold blameless All Nations 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 All Nations Church, as well as of any medical treatment authorized by the supervising individuals representing All Nations Church. This consent and authorization is effective only when participating in or traveling to events of All Nations Church.

I consent to All Nations Church taking pictures /videos of my child and using them in print/digital media.

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I understand that the below SIGNATURE is confirmation and consent to everything included in the above form.

SIGNATURE

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