WAIVER & MEDICAL RELEASE FORM
Field Trips and Special Events

Activity: RIVERVIEW CAMP, CHESLEY, ON Date: THURS SEPT 8-SAT SEPT 10

Chaperones PASTOR JEFF & PASTOR AARON

Name of Child: ________________________________________________________ Age: ___________

Address __________________________________________________________________Postal Code______________________

Phone ____________________________________School _________________________________________________________

Does you child have any severe allergies? (bee stings, food, penicillin, other drugs) YES______________NO ______________
If yes, please explain: _______________________________________________________________________________________

Does you child have any life-threatening allergies? YES _____________ NO _____________________
If yes, please explain: _______________________________________________________________________________________

Is your child bringing any medication with him or her? (Antibiotics, ventilator, Ritalin) YES _____________ NO ______________ 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 ________
If yes, please explain: ________________________________________________________________________________________

Check if your child currently, or within the last three months, has had any of the following:
Appendicitis Ear Infection Hay Fever Mumps
Asthma Epilepsy Hepatitis Severe Stomach Ache Tonsillitis
Bedwetting Diabetes Measles (Red) Sinusitis
Chicken Pox Fainting Measles (German) Other

Date of last Tetanus shot: _______________________

Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Logos Christian Family Church, its staff, and its volunteers are hereby released from any liability. In the event that your child requires special medication, x-rays or treatment, the parents/guardians will be notified immediately. In case of surgical emergency, I hereby give permissions to the physician selected by Logos Christian Family Church to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

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 ___________________________________________________________________________________

Parent/Guardian's Signature: _______________________________Date: ____________________________________

Logos Christian Family Church shall not be liable or responsible in any way for any person or consequential injury of any nature whatsoever sustained by the Undersigned, or for any loan or damage or injury to any property belonging to the Undersigned. The Undersigned shall indemnify and hold harmless, Logos Christian Family Church their members, agents and employees, from and against all claimed, demands, losses, costs, damages, actions, suits, or proceedings by any third party that may arise out of, or may be attributable to all activities performed by or carried out by Logos Christian Family Church or the Undersigned.

Logos Christian Family Church
Children's/Youth Ministries, 3535 Dixie Rd., Mississauga, On. L4Y 2B3
Phone: 905 624-9261, Fax 905 624-6780, e-mail: mail@logoschurch.ca