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Home My WebLink AboutChildren's Participant Waiver 2017.pdf Personal information requested on this form is collected under the authority of the Freedom of Information and Privacy Act (Act). Unless otherwise specified, the information gathered will be used by the City of Maple Ridge for pursuant to S.26 of the Act. Questions about the collection, use, and disclosure of this information should be directed to Laurie Darcus, Manager of Legislative Services and FOI Head, Clerks Department, City of Maple Ridge, 11995 Haney Place, Maple Ridge, BC V2X 6A9, ldarcus@mapleridge.ca, 604-467-7482. Children’s Programs Parent/Guardian Consent & Participant information Form Required for Participation Program Name: ______________________________ Date: ________________________ Participant Child’s Name: ____________________________ ______________________________________ First Name Last Name Child name preference:____________________ Age: _________ Gender: Male □ Female □ Birth Date (DD/MM/YYYY):____________________ Care Card #: ____________________________ Child’s 1st Language: _____________________ Child’s 2nd Language: ________________________ Does your child have a life threatening allergy? □ Yes or □ No (check one) What is the life threatening allergy to? ________________________________________________ *If YES, please complete the Special Information Section in this waiver. Home Address: _____________________________________________________________________ Postal Code: _________________________ Home Phone : _________________________________ Contacts Parent/Guardian Name (s): __________________________________________________________ Phone #(home): ___________________(work): ________________ (cell): ____________________ Alt Phone: ______________________________ Alt Phone: ________________________________ Emergency Contact: _______________________________ Relationship: _____________________ Phone#(home): _________________ (work): ____________________ (cell): __________________ Pick Up Authorization I hereby authorize the following people to pick up my child, at the program location in the event parent(s)/guardian(s) are unable to and have contacted the Parks & Recreation staff prior to pick up. 1. ___________________________ Phone Number: _______________________________ 2. ___________________________ Phone Number: _______________________________ 3. ___________________________ Phone Number: _______________________________ 4. ___________________________ Phone Number: _______________________________ Photos I, the undersigned, parent/guardian do hereby agree to all the individual(s) names herein to be photographed and pictures to be used solely for the purposes of promoting City of Maple Ridge programs. □ YES or □ NO (check one) Personal information requested on this form is collected under the authority of the Freedom of Information and Privacy Act (Act). Unless otherwise specified, the information gathered will be used by the City of Maple Ridge for pursuant to S.26 of the Act. Questions about the collection, use, and disclosure of this information should be directed to Laurie Darcus, Manager of Legislative Services and FOI Head, Clerks Department, City of Maple Ridge, 11995 Haney Place, Maple Ridge, BC V2X 6A9, ldarcus@mapleridge.ca, 604-467-7482. Children’s Programs Parent/Guardian Consent & Participant information Form Required for Participation Medical Information Please ensure all information is completely filled out as this information is used is for staff to provide medical treatment and information for your child in the event of an illness or injury. Does your child: (Identify the child’s name if they have any of the following considerations) Have any medical conditions (i.e. Asthma)? □ YES or □ NO if yes please explain below: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Take any medication (include type, dosage, times of self-medication)? □ YES or □ NO if yes please explain below: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Have any allergies (include those to food, medication, sunscreen and environment)? □ YES or □ NO if yes please explain below: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Have any limitations that would mean the child could not participate in activities? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Have any fears that leaders should be aware of (e.g. water, bees)? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Medical Release: It is our policy to notify a parent when a child is ill or needs medical attention. In the event we cannot contact you and we need to get immediate help for your child, we require a signed consent to do so. 1. I give consent for my child to be taken to the nearest emergency medical centre by ambulance when I cannot be contacted. 2. I give consent for my child to receive medical treatment. Signature of parent/guardian ___________________________ Date: _______________________ Witness: _____________________________________________ Personal information requested on this form is collected under the authority of the Freedom of Information and Privacy Act (Act). Unless otherwise specified, the information gathered will be used by the City of Maple Ridge for pursuant to S.26 of the Act. Questions about the collection, use, and disclosure of this information should be directed to Laurie Darcus, Manager of Legislative Services and FOI Head, Clerks Department, City of Maple Ridge, 11995 Haney Place, Maple Ridge, BC V2X 6A9, ldarcus@mapleridge.ca, 604-467-7482. Children’s Programs Parent/Guardian Consent & Participant information Form Required for Participation Important Information Does your child know how to swim? □ YES or □ NO (check one) Current level of swim lesson: ____________ Do you give permission for staff to administer sunscreen to your child? □ YES or □ NO (check one) Please list any family information or special instructions the Maple Ridge Parks, Recreation & Culture staff should be aware of while your child is in care: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Please list any other comments or concerns that you have: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ I consent to my child’s participation in the Program. I am aware that there are risks associated with the participation in the program, including the risk of injury, and I consent to my child’s participation in spite of such risks. I acknowledge that it is my responsibility to advise the City of Maple Ridge of any medical or other conditions which may affect my child’s participation in Maple Ridge Parks, Recreation & Culture programs and have listed them above. I have read this form and understand and accept its terms. ________________________________________ __________________________________________ Parent/Guardian Signature Parent/Guardian Printed Name ____________________________________ ______________________________________ Date Parent/Guardian Email