Summer Camp 2015 Waiver .pdf

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Original filename: Summer Camp 2015 Waiver.pdf
Title: Microsoft Word - Waiver_and_medical_release.rtf
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RCEFC Activity Program Waiver and Medical Release Form
Note: Before an activity, the person in charge should store a copy of this waiver in a safe storage area and takes another copy
on the outing.
Description and location of Activity:
Departure date and time:

EM Summer Retreat @ Trinity Western University

July 31, 2015

Returning date and time:

August 3, 2015

Full Name of participant:
First

Last

Middle

Birth date (N/A for adult):
Full Address:
Parent/guardian/caregiver name(s) (if under 19):
Contact number of Parent/guardian/caregiver (if under 19):
Does the participant have any severe allergies or other medical condition that leaders should be aware of?
No

Yes

If yes, please list and explain:

Participant's Care Card number:
Contact person in case of emergency (if under 19, someone other than parent/guardian/caregiver):
Name:

Phone:

I/WE acknowledge that participation in this event involves certain inherent risks, dangers and hazards which can result in
personal injury (major or minor) or death. The risks include, but are not limited to: actions of oneself; actions of other people;
weather and/or other natural conditions; travel; conditions of facilities and equipment; personal health and fitness. I/WE hereby
assume all of the risks of participating in this event.
I/WE agree that Richmond Chinese Evangelical Free Church (RCEFC) and its officers, employees, agents and volunteers SHALL NOT
BE LIABLE for any injury to my person or loss or damage to my personal property arising from, or in any way resulting from, my
participation in these activities.
I/We understand that In the event of injury requiring medical attention, I give permission to the leaders acting on behalf of
RCEFC to seek medical treatment for me/my child. I/WE understand that reasonable attempts will be made to contact the
parent/guardian should such situation occur.
I/WE declare having read and understood the above WAIVER AGREEMENT AND MEDICAL RELEASE in its entirety and hereby
consent to participate acknowledging all of the foregoing.

Participant Signature

date

Parent/Guardian Signature (if participant is under 19)

date


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