Shipwrecked VBS Registration Form (8.5”x14”)Redeemer Bible Church, 3017 Montrose Road, Niagara Falls, L2E 6V6

I _____________________________________, being the parent/legal guardian and having the legal custody of _________________________________________, a minor, do hereby consent to said child participating in activities of Redeemer Bible Church of Niagara Falls. I do hereby release, discharge and exonerate Redeemer Bible Church, and all persons acting as teachers, leaders or volunteers on said activities from any liability whatsoever resulting from personal injury to said minor or damage to property of said minor which may occur at said activities or connection therewith. I do hereby certify that I assume full responsibility and liability for any acts committed by said minor during activities, and trips related thereto resulting in injury or damage to the property of another. I do hereby acknowledge that I understand that this release is being relied upon by Redeemer Bible Church of Niagara Falls, and teachers, leaders or volunteers overseeing the children in said activities, and without this instrument being executed by me, said minor would not be permitted to engage in activities related thereto. I, do hereby authorize the officials of Redeemer Bible Church to contact directly the person named in this authorization, and do authorize ______________________________________ or ___________________________________ (Physician) (Hospital)to render such treatment as may be deemed necessary in an emergency, for the health of said child. In the event physicians, other persons named in the authorization or parents cannot be contacted, the church officials are hereby authorized to take whatever action is deemed necessary in their judgement, for the health of the aforesaid child. I will not hold Redeemer Bible Church financially responsible for the emergency care and/or transportation for said child. Parent/Guardian Name (please print): __________________________________________________Church Affiliation/Home Church: ___________________________________________________Email: _______________________________________________________________________Phone #: ________________________ □ I am interested in hearing about future events at RBC.Emergency Contact: _______________________________ Phone #: ______________________Allergies/Behavioural Needs: ______________________________________________________Name of Child: ________________________________________________________________Grade Child is Entering as of September 2019: _______ (Child must have completed Gr.JK-5)Health Card Number: _______________________________ Expiry Date: _________________

I hereby consent that my child’s photograph may be taken for the VBS Slideshow.

I DO NOT want my child’s photograph taken or included in the VBS Slideshow. NOTE: Photographs taken WILL NOT be used online or for promotional purposes.

Parent/Guardian Signature: ___________________________________ Date:______________