Child's Name *

First Name

Last Name

Child's Birthdate *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Cell Phone *

(###)

###

####

Parent/Guardian Home Phone

(###)

###

####

Does the Kipling People’s Church have permission to take photos of your child participating in activities for use in church publications (website, newsletter, special events, etc?) *

Yes

No

I, the parent/guardian give permission to the above-named participant to participate onsite at The Kipling People's Church for the Kid's Day Camp on April 5, 2024. *

Yes

No

I, the parent/guardian of the above-named participant, release The Kipling People's Church, directors, staff, and leadership team from any loss, personal injury, accident, misfortune, or damage to the above named or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named child. Saskatchewan Health Care or equivalent medical insurance must cover each child. *

Yes

No

The parents/guardians submitting this application are those having legal custody over the child. Conditions of custody, if applicable, will be fully communicated in writing to The Kipling People's Church including a photocopy of the section of any court order referring to visitation rights, where applicable. *

Yes

No

The signature of the parent/guardian on this application shall give the Leader(s) or staff person(s) the right to arrange for any special services or other requirements necessary for the best interest of the child and shall give the Leader(s) or staff person(s) the right to approve and obtain medical attention necessary for the child's welfare and good health including ordering injection, anesthesia, or surgery. In such a situation, attempts will be made to notify the parents/guardians as soon as possible. The parents/guardians are responsible for any additional expense that may result from such services. *

Yes

No

Signature: By entering my name in the following box, I understand this will act as my legal signature and consent in agreement with the above waiver questions. *

First Name

Last Name

Date *

MM

DD

YYYY