GEMS Registration Personal Information & Permission and Liability Release 2023/2024

We are excited to begin GEMS on February 28, 2024.

Information received is confidential and is being gathered for the purposes of serving your child while in the care of Community Christian Reformed Church. Any medical information collected here serves to authorize CCRC, its staff and volunteers, to obtain medical assistance in emergencies

Participant Information (GEMS girl).

Name

Student Home Address

Birth date

Current Grade

2 3 4 5 6 7 8

Parent/Guardian Information

First Name

Last Name

Parent/Guardian perferred phone #

Parent/Guardian Email

This address will receive a confirmation email

Home Address (you can type "same as above")

Emergency Contact Information

Emergency Contact

Phone # of Emergency Contact

Relationship to participant

Family Physician

Physician Phone

Health Card Number

Health Card # / Medical Release I, the parent or legal guardian of child listed above, a minor, by providing this health card #, hereby authorize and give permission to the physician or medical practitioner, selected by Community Christian Reformed Church to hospitalize, secure proper treatment including but not limited to the prescription of medications, diagnostic studies, and any other medical procedure for my child as deemed necessary by the physician under the circumstances. It is understood that this authorization is given in advance of any specific medical treatment being needed, and is given to provide authority to the physician to render that care which in exercise of his or her best judgment is advisable.

Yes No

Does this participant have any allergies or medical conditions?

If yes, please explain or if No type N/A

Should this participant be restricted from any activities?

If yes please explain or if No type N/A

Abuse Prevention Policy Agreement

I will comply with the Community Christian Reformed Church Abuse Prevention Policy regarding prompt pick-up of participants:

“Participants should be picked up within 15 minutes of the end of any activity.” In accordance with the policy, “If not picked up within 10 minutes, a Volunteer/leader will telephone the Parent(s)/Legal Guardian to ensure someone is coming to pick up the participant.”

By selecting Yes you are agreeing to comply with the Abuse Prevention Policy referred to above.

Yes No

Release and Waiver of Liability

I/We, the parent(s) or Guardian of the above mentioned child, in consideration of my/our child being permitted to enter the Community Christian Reformed Church (hereafter Community CRC) property, and being permitted to participate in Community CRC activities and events, AGREE TO WAIVE, RELEASE, DISCHARGE AND COVENANTS NOT TO SUE, its employees, officers, directors, servants and agents from all liability to the child, to myself, or any personal representative of either, assigns, heirs, and next of kin, for any and all claims for damages, for death, personal injury or property damage, suffered by me or my child while participating in any Community CRC event or activity.

I/WE UNDERSTAND THAT THIS RELEASE AND WAIVER OF LIABILITY applies to any claims occurring from injury to person or property, whether caused by negligence of Community CRC or otherwise. I/We acknowledge that the intent of this RELEASE AND WAIVER OF LIABILITY is to prevent Community CRC from being held liable for injuries to person or property, and that selecting YES constitutes my/our agreement and the agreement of the child listed above, not to hold Community CRC responsible for any damages, losses, injuries to person or property, as a result of any negligence or other wrongful conduct on the part of Community CRC or on the part of other third parties.

I/We ALSO AGREE TO INDEMNIFY AND HOLD HARMLESS Community CRC from any loss, liability, damage, or cost that Community CRC may incur due to the presence of myself or said child, upon Community CRC premises or in any way using any of Community CRC facilities or attending any events of Community CRC, whether caused by negligence of Community CRC or otherwise.

FURTHER, I/WE EXPRESSLY AGREE THAT THIS RELEASE AND WAIVER OF LIABILITY is intended to be as broad and inclusive as is permitted by the law in the Province of Ontario. If any portion is held to be invalid, it is agreed that the balance shall continue in full legal force and effect.

I/We further agree that this Release and Waiver of Liability shall be valid for the program season or year.

I/We have read and voluntarily agree, and further acknowledge that no oral representations, statements, or inducements apart from the written agreement have been made.

By selecting Yes you are digitally signing that you agree to the Liability release above.

Yes

MEDIA Release I give Community Christian Reformed Church the permission to photograph my child and use his or her picture solely for the church’s website or social media platforms.

Yes No

Electronic Signature

By entering my name in the above box, I am providing my digital signature to this form.

Thank you for completing and submitting the form.

GEMS Registration Personal Information & Permission and Liability Release 2023/2024

Description

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