SUMMER J.A.M. RELEASE FORM

MEDICAL

Alberta Health Care # _____________(required at time of registration)

Does your child have any special needs we should be aware of?

Physical, Asthma, Behavioural, Emotional, Learning Disabilities, Social

Allergies: Medication/Other

My child has the following special needs/allergies

______________________________________________________________________

______________________________________________________________________

My child uses the following medication in support of the above mentioned special needs/allergies

______________________________________________________________________

______________________________________________________________________

ATTENTION - This medical and legal release must be completed and signed in order for your child to participate in SUMMER J.A.M. 2014

I_______________________________ (parent/guardian) give my permission to

________________________________(child) to participate in Morinville Alliance Church

Weird Animals Summer J.A.M 2014.

In the unlikely event of an emergency I authorize Morinville Alliance Church to act on my behalf and to have my child treated by an accredited physician in an approved emergency clinic or hospital. I further release Morinville Alliance Church and its officers and/or leadership in the event of an accident enroute, during and returning from the daily activities of Weird Animals Summer J.A.M 2014

Name of parent/guardian (please print)______________________________

Signature of parent/guardian______________________________________

Photo/Video release

I hereby give my permission for images of my child captured during Morinville Alliance Church Summer J.A.M. 2014 through video/photo/digital camera to be used solely for the purposes of Morinville Alliance Church promotional material and publications, and waive any rights of compensation or ownership thereto.

Signature of parent/guardian_________________________________ Date____________