Child's Name *

First Name

Last Name

Guardian's Name *

First Name

Last Name

Phone *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Emergency Contact

First Name

Last Name

Second Phone

Secondary Emergency Contact

(###)

###

####

Allergies or Health Concerns *

None

Yes

Waiver *

I have authority to, and I choose to give permission for the children listed on this registration, waiver, and medical release form to attend the Thursday Open Gym at Parkdale School hosted by Steel City Baptist Church (SCBC), to participate in all of the activities involved, including, but not limited to: games, sports, and partaking in food and beverages. I understand that pictures and video may be taken of my child(ren) and used for social media or promotional purposes. In the case that the volunteers, or staff of SCBC recognizes a health situation as urgent, I understand that they may need to authorize medical treatment and release or obtain medical or personal information that may be necessary for the care or treatment of these children. I choose to waive, release, hold harmless and agree not to sue Steel City Baptist Church located at 92 Parkdale Ave N. Hamilton, ON, L8H 5W9 (including its Pastor, staff, members, volunteers, or affiliates). I verify that the information on this form is true and accurate.

I AGREE