Release Back to Work Form by vlp17176


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									                                              Giving Back
                       Medical Release, Permission Form, & Photo/Video Release
                          st                     st
Effective dates: June 1 , 2010 to August 31 , 2010                                           Please print in ink.

                                                  Personal Information

Name: _______________________________________________ Age:______ Birthday: ______/______/_____
           LAST           FIRST       MIDDLE INITIAL                         MM     DD     YY

              Male             Female      E-mail: __________________________________________________

Address: _______________________________________City: _______________ Postal Code: ____________

Home Phone #: ______________________ Pager/cell:_____________________ Other #: ________________

Mother’s name: ________________________ Home #: ___________________ Work #: __________________

Father’s name: ________________________ Home #: ___________________ Work #: __________________

Emergency contact: _______________________ Relation: ______________Contact #: ___________________

Physician: ____________________________________________ Office #: ________________________

Manitoba Health Number: ____________________________________________________________________

School attended 2008-09: ________________________________ Last Grade completed: ________________

How did you hear about us? __________________________________________________________________

Would you like to be notified by the Giving Back staff or Church employees in the future regarding any youth
activities we feel your child may be interested in?

                     Yes, I would like to be contacted in the future     No, thank you


                                                      Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness,
propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the
staff should be aware, and what, if any action of protection is required on account thereof. Submit this
notification in writing and attach it to this form. Include names of medications and dosages that must be taken.

Check the following areas of concern for this student. If necessary, add another page
with details.

    1. For your child’s safety and our knowledge, is your child a:

           Good Swimmer                       Fair Swimmer                      Non-swimmer

    2. Does your child have allergies? If so, please list all of them (include food allergies).

Contact: Kyle Martin                                                                                                1
                     • 471-6913 (Phone)
                     • (E-Mail)
                     • (Website)
                                             Giving Back
                      Medical Release, Permission Form, & Photo/Video Release

    3. Does your child suffer from, or has ever experienced, or is currently being treated for:

           Asthma                            Epilepsy/seizure disorder         Frequently upset stomach

           Heart Trouble                     Physical handicap                 Diabetes

    4. Approximate date of last tetanus shot: ___________________________

    5. Does your child wear:                 Glasses?                          Contact lenses?

    6. Feel free to make any other additional comments.





                                           Medical Release/Permission Form

For your information, we expect each student to conform to these rules of conduct:
    • No possession or use of alcohol, drugs, or tobacco.
    • No fighting, swearing, bullying, weapons, fireworks, lighters, or explosives.
    • No offensive or immodest clothing.
    • Participation with the group is expected.
    • Respect property.
    • Respect one another, staff, volunteers, and adult leaders.
    • Respect and comply with event schedules.

Students who fail to comply with these expectations may be sent home at their parents’ expense.

I, the student, have read the rules of conduct and the above evaluation of my health. I agree to abide by the
stated personal limitations and code of conduct.

Student signature: ____________________________________________ Date: ________________

Activities may include but are not limited to: outdoor sports/games, water activities (ie. Water balloons, Fun
Mountain, Vimy Ridge Water Park, and Swimming), baking, cooking, crafts, tie-dying, Tae Kwon Do instruction,
off-site activities (ie. YMCA, Winnipeg Zoo, IMAX, Children’s Museum, Fort Whyte, Goldeye’s Game etc.), and
more. Transportation to and from locations will be via foot, Winnipeg Transit Bus, or Chartered Bus. If you
desire to limit your child’s participation in any event, please submit your wishes in writing to the program leaders
prior to that event.
_______________________________(Name of student) has my permission to attend all Giving Back activities
sponsored by the Urban Green Team from ____________ (date) to _____________ (date).
Contact: Kyle Martin                                                                                               2
                    • 471-6913 (Phone)
                    • (E-Mail)
                    • (Website)
                                             Giving Back
                      Medical Release, Permission Form, & Photo/Video Release

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the
Giving Back program, its staff, and the Church of any liability against personal losses of named child.

I/We, the undersigned, have legal custody of the student named above, a minor, and have given our consent for
him/her to attend events being organized by Giving Back. I/We understand that there are inherent risks
involved in any event, and I/we hereby release the Church, its employees, agents and volunteer workers from
any and all liability for any injury, loss, or damage to person or property that may occur during the course of
my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we
consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event
treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold
such person free and harmless of any claims, demands, or suits for damages arising from the giving of such
consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should
the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the
health insurance information provided above is accurate at this date and will, to the best of my/our knowledge,
still be in force for the student named above. I/We also agree to bring my/our child home at my/our own
expense should they become ill or if deemed necessary by the program leaders.

Parent/guardian signature: ______________________________________ Date: ________________

                                                 Photo/Video Release

At various times throughout the summer, photographs and/or video footage may be taken of the different events
that your child will be taking part in. These photographs will only be used within the context of Giving Back (ie. to
promote Giving Back in future years and to provide students with a CD copy of the summer pictures at the end
of August).

I/We hereby give permission for photographs/video footage captured of __________________ (Name of
Student) during regular and special outings throughout the Giving Back Summer Drop-In Program to be used
solely for the purposes of Giving Back.

Parent/Guardian Signature: _____________________________________ Date: ________________

At any time, ___________________ (Name of Student) has permission to:

            Leave on their own                        Be picked up by: ___________________________



If someone not on the above list will be picking up said student or, if said student will be leaving on their own,
I/We will contact the Giving Back staff to inform them of this exception.

Parent/Guardian Signature: _____________________________________ Date: ________________

Contact: Kyle Martin                                                                                                 3
                    • 471-6913 (Phone)
                    • (E-Mail)
                    • (Website)

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