waiver form to be handed in

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REGISTRATION / WAIVER FORM

TO BE HANDED IN

Name Phone

Age

Cell

Grade

Email Address

PC

School Parent’s Names The following must be completed by all those under the age of 19 unless traveling with their parents.

I give permission for my above-named child to join: Name of Ministry_________________________________________________________ Event____________________________________________________________________ Dates of Event___________________________________________________________ I understand that the group will be traveling by van, car or bus. I hereby release NLCC, its staff and sponsors, from responsibility and liability for any injury or illness that my child may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to any x-ray examination, medical, dental or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office or in any hospital. I expect to be contacted as soon as possible. Signature of natural parent or legal guardian _____________________________________________________Date _____________________________

OFFICE USE ONLY (do not fill in) Amount of Payment _____________________

Date Received______________________

Cash / Credit / Debit / Cheque #___________

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EMERGENCY / MEDICAL INFORMATION

TO BE HANDED IN

As standard procedure, we require the following information from everyone participating in a trip with North Langley Community Church Event Name

Event Dates

Name of team member (as shown on passport)

Medical Card Number

Birth Date

Province Issued

Doctor’s Name

mm

dd

yyyy

Doctor’s Phone

IN CASE OF AN EMERGENCY, PLEASE CONTACT (Be sure contact is available during the trip) Name

Relationship

Home Phone

Business

Name

Cell Relationship

Home Phone

Business

Cell

MEDICAL INFORMATION Do you have any medical conditions and/or are you seeing a physician for any reason?

Yes

No

Yes

No

Yes

No

If yes, please explain Do you take prescription drugs? Please specify Do you have any allergies? Please specify

THIS INFORMATION WILL BE KEPT CONFIDENTIAL I declare by my signature below that all information is correct and I have disclosed all known medical conditions. Print Name

Date

Signature (of parent or guardian if participant is under the age of 19)

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NLCC’S EXPECTATIONS & CONDUCT TO BE HANDED IN As a group we will be representing North Langley Community Church, therefore you must agree to abide by the following standard of conduct:           

No complaining about anything—remember, everything is not about you!! You are required to join in on all group activities Everyone must help with chores & clean up You must show up for all meals together There will be a 12 am (midnight) curfew & you MUST obey it We have a buddy system – never go anywhere by yourself! No PDA (public displays of affection) Don't go into anyone else's tent/room – especially the opposite sex There is to be no smoking for anyone under the age of 16 There is to be no alcohol or illegal drugs of any kind There are to be no fireworks, knives or firearms brought to this event

YOU WILL BE SENT HOME AT THE EXPENSE OF YOUR PARENTS IF NECESSARY I agree to abide by all these rules and I understand they are put in place to allow me to have the most fun I can in the safest possible way. Name of Participant (print clearly)______________________________________________________ _______________________________________________________________________________________ Student Signature Date

Name of Parent (print clearly) __________________________________________________________ _______________________________________________________________________________________ Parent Signature Date

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