Cornerstone Baptist Church in Orillia: Youth Dodgeball

Student's Name *

Parent's Email *

Has your information in Section 1 changed since the last waiver you completed?

Yes

No

If your information has not changed, you can leave the rest of Section 1 blank and move to Section 2 and 3

Student's Date of Birth

Address

Student's Phone Number

Parent's Phone Number

Student's Health Card Number

Family Doctor

Doctor Phone Number

Allergies / Special Notes

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

Yes

No

If yes, please explain.

Is your student bringing any medication with him/her?

Yes

No

If yes, please list.

Parent/Guardian Name:

In case of an emergency and we are unable to contact you at the phone numbers listed above, please provide an alternate contact name, relationship to your student and phone number who we can speak with.

Medical Waiver *

I agree

I disagree

I/we, the parents or guardians named above, authorize Josh Scott, Noah Ecker or one of the Cornerstone Baptist Church, Orillia Ministry Personnel, to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.

Indemnification Waiver *

I agree

I disagree

I/we, the parents or guardians named above, undertake and agree to indemnify and hold blameless Cornerstone Baptist Church, Orillia, the Board of Elected Elders and Ministry Personnel from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Cornerstone Baptist Church, Orillia as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to or from events of Cornerstone Baptist Church, Orillia.

Photos Waiver *

Brochures/Promotional Material

Church Service

Website

Newsletters

None

I/we, the parents or guardians named above, GRANT PERMISSION for the reasonable use of pictures containing our student in any or all of the following ways (please indicate any or all):

Activities Waiver *

I have read, understood and agree with the above and sign it to cover the activities listed below.

Please check which events your student will be attending: *

Dodgeball at Orillia Christian School

Comments

Youth Dodgeball

Who's Ready For Dodgeball?

When: Tuesday, April 8th | 6-8pm
Where: Orillia Christian School | 505 Gill St, Orillia

Under 18 Years of Age - Please Complete the Following Waiver:

Under 18 Dodgeball Registration & Waiver

SECTION 1

SECTION 2

18 Years of Age or Older - Please Complete the Following Waiver:

Adult Dodgeball Registration & Waiver

Indemnity Waiver:

April 8th: Dodgeball

Events