INFORMED CONSENT AND
EMERGENCY MEDICAL FORM

*Please Note: You must complete this form for EACH CHILD attending once per calendar year.

Please ensure that your information with us is up to date.

The personal information is collected below is to be used in the event of a medical emergency in the County Sportsplex program(s).

Child's First name

Child's Last name

Primary Parent/Guardian Full Name

Child's Date of birth

Year

Month

Day

Phone

Alternate Parent/Guardian Full Name

Relationship to Child

Phone

Local Emergency Contact - Full Name

Phone

Does your child have any allergies?

Yes

Is your child on any medications?

Yes

If you answered yes to any of the questions above, please supply additional information.

Does your child have any other pertinent medical information, restricted activities, or behavioural issues?

Informed Consent: I authorize my child to participate in the Nustadia Recreation Inc. program, which I understand may involve, but is not limited to the following activities: walking to and from the park, playing on the Bouncy Castles, indoor/outdoor games and activities and playing on playground equipment. I am aware and acknowledge that certain risks of injury are inherent to participation in sports and recreational activities. These types of injuries may be minor or serious and may result from one's actions, or the actions or inactions of others, or a combination of both. Nustadia Recreation Inc. may secure such medical advice and services as it, in its sole discretion, may deem necessary for the participant's health and safety and I shall be financially responsible for such advice and services. I declare that I have read, understood and agree to the contents of the Informed Consent Form in its entirety.*

I declare that I have read, understood and agree to the contents of the Informed Consent Form in its entirety.

YES

I agree that the Nustadia Recreation Inc. or its employees or volunteers shall not be liable for any injury to the participant or loss or damage to the participant's personal property arising from or in any way resulting from the participation in these activities.

YES

Photo Consent: I hereby consent to the use of and grant to the Nustadia Recreation Inc. the right to use, for the purposes of promoting the recreational programs or services, any photographs taken of the minor specified above while they attend the daycamp program may be used for future publications & promotions. I grant such consent as parent and/or guardian to the above minor pursuant to Section 17(2)(a) of the Freedom of Information and Protection of Privacy Act. I understand no other personal information about the minor will be released by the Nustadia Recreation Inc. without my permission.

Photo Consent

Yes, I do consent to the above photo terms for my child

No, I do not consent to the above photo terms for my child

Sign Out Consent: At the end of each day children must be signed out before being permitted to leave the day camp. You may choose to have your child signed out by the parent/guardian or by other pre-designated adults. Other than the Primary/ Alternate Parents/Guardians noted above and the Local Emergency Contact if you wish to designate other adults permitted to sign the above child out from Nustadia Recreation Inc. day camps please list them below:

Sign out consent names

The personal information on this form is collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act (FOIP) to be used in the administration of Nustadia Recreation Inc. Programs and in the event of a medical emergency and will be provided exclusively to qualified personnel. If you have any questions regarding the collection of this information please contact The J.D.A. County Sportsplex at 780-830-7407 or info@cgpsportsplex.com

I have read and agree

Full Name

Today's Date

I declare that the info I’ve provided is accurate and complete.

INFORMED CONSENT AND EMERGENCY MEDICAL FORM

INFORMED CONSENT AND
EMERGENCY MEDICAL FORM