NEMBY Jr.

Swimming Permission Form

DATE: Thursday, April 11th LOCATION: Abe and Agnes Wiens house, 1178 Concession 6, Niagara on the Lake TIME: 6:30 PM to 8:30 PM COST: Free CONTACT: Mark Durksen if you have any questions: 905-937-6900 or markdurksen@hotmail.com OTHER INFORMATION: Bring a bathing suit and towel.
----------------------------------------------------------------------------Name: _____________________________________________________ Phone #: _________________________________ Address: ___________________________________________ City: _________________________ Postal Code: ________ OHIP #: ____________________________________ Allergies: _________________________________________________ Medications being taken: ________________________________________________________________________________ Emergency Contact Person: _________________________________________ Phone #: ____________________________ Student Co-operation Agreement Were glad that youre coming swimming with us and we hope that youll have a great time. To keep things enjoyable for everyone, there are a few simple guidelines to remember and live by: Parental Permission I give my permission for the above named student to go swimming with NEMBY at Abe & Agnes Wiens house. I understand that all reasonable safety precautions will be taken at all times by NEMBY youth leaders during the event - Be respectful to the the owners of the house and follow all described above. I understand the possibility of unforeseen hazards and know the possibilities of risk. I agree not to hold of their rules and guidelines. - Respect the students and adult leaders you are with. If an Scott St. MB Church, Fairview MB Church or Grantham MB Church or their employees or volunteers liable for damages, adult leader tells you to do something, obey them. losses or emergency. I hereby authorize an adult leader as I have read the above Co-operation Agreement and, by agent for me, to consent to any X-ray examination, medical, signing below, agree to abide by it. dental or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon or dentist (as Student Signature: appropriate) licensed to practice under the law of Ontario where the services are rendered, either at a doctors office or _________________________________ in a hospital. I expect to be contacted as soon as possible in this event. Date Signed: ___________________________ Signature of Parent/Guardian: ___________________________ Date signed: __________________