Extreme Adventure Release Form CHILD'S INFORMATION Child's First & Last Name Gender Male Female Upload your child's picture Street Address City Province Postal Code Height (ft and in) Weight (lbs) Date of Birth Age 6 7 8 9 10 11 12 13 14 15 16 17 18 MEDICAL INFORMATION Name of Doctor Doctor's Phone Number Personal Health Number Does the child have any allergies? Yes No If yes, what are they and what is the child's reaction? Does the child have any dietary needs or restrictions? Yes No If yes, what are they? Does the child have any other medical conditions, behavioural, or emotional concerns? Yes No Please explain all medical conditions, behavioural, or emotional concerns, including symptoms List all medications the child takes between 10am and 3pm *Epi-Pen must be brought if needed (one per line) I grant the designated LEADER permission to give my child over-the-counter medications if necessary Yes No Parent/Guardian Intials CONTACT INFORMATION Parent/Guardian First & Last Name Parent/Guardian Phone Number Parent/Guardian Email Emergency Contact #1 Full Name Phone Number Emergency Contact #2 Full Name Phone Number PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR ACCEPTANCE MEDICAL RELEASE: I authorize the administration of any first aid treatment necessary at Extreme Adventures for my child. In the case of a medical emergency, I authorize my child to be transported by designated leaders or arrange for transportation to the nearest medical or hospital facility. In such an emergency I hereby give permission to the physician involved to secure proper treatment for my child. In the event extraordinary transportation or medical treatment is required, I agree that Extreme Outreach cannot accept the financial responsibility. I expect to be contacted as soon as possible. LIABILITY WAIVER: Extreme Outreach reserves the right to dismiss a child who in their opinion is a hazard to the safety and the rights of others, or who appears to have rejected the rules as directed by the designated leaders. A child who must be sent home due to disciplinary action or homesickness must be picked up by a parent(s) or designated emergency contact. I am confident that Extreme Outreach staff will do their best to give my child the necessary support and supervision needed and I understand that the safety and health rules will be observed. To the best of my knowledge, my child is in good health and physically, emotionally, and socially able to participate in all activities. I give my child permission to participate in all activities. If my child is not physically, emotionally, or socially able to participate in all activities, I understand that Extreme Outreach does not have the people for one-on-one with my child and they may be unable to attend. I hereby release Extreme Outreach Society and its personnel from all claims and damages arising from any accidents or injury caused by my child’s participation in the program or by any transportation to and from all locations. Extreme Outreach is not responsible for lost, stolen, or damaged items during my child’s participation. I agree that photos or videos of my child taken at SuperKids may be used in future Extreme Outreach and/or SuperKids promotional material. If I am not in agreement with this, I will give written notice to Extreme Outreach that the photos and videos are not to be used for this purpose. The parent/guardian submitting this application are those having legal custody over the child. Conditions of custody, if applicable, will be fully communicated in writing to Extreme Outreach including a photocopy of the section of any court order referring to the visitation rights. To indicate your understanding of the above, place a check mark in the box below and provide your full name and date: I understand and agree Full Name of Parent/Guardian Date Signed Send Form
