NEMBY Jr.

Port Dalhousie Permission Form

DATE: Thursday, June 6th TIME: 6:30 - 8:30 PM LOCATION: Port Dalhousie, meeting and pick-up at the carousel CONTACT: Mark Durksen if you have any questions: 905-937-6900 or markdurksen@hotmail.com OTHER INFORMATION: Bring money for ice cream if you would like some. For liability reasons we will not be swimming.
Name: _____________________________________________________ Phone #: _________________________________ Address: ___________________________________________ City: _________________________ Postal Code: ________ OHIP #: ____________________________________ Allergies: _________________________________________________ Medications being taken: ________________________________________________________________________________ Emergency Contact Person: _________________________________________ Phone #: ____________________________

Student Co-operation Agreement Were glad that youre coming to the Port Dalhousie 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 participate in the event at Port Dalhousie. I understand that all reasonable safety precautions will be taken at all times by NEMBY youth leaders during the event described above. I understand the possibility of unforeseen hazards and know the - Be respectful to the area and facilities. possibilities of risk. I agree not to hold Scott St. MB Church, - Do not be disruptive to other people. They are there to Fairview MB Church or Grantham MB Church or their enjoy Port Dalhousie as well. - Respect the students and adult leaders you are with. If an employees or volunteers liable for damages, losses or emergency. I hereby authorize an adult leader as agent for adult leader tells you to do something, obey them. me, to consent to any X-ray examination, medical, dental or I have read the above Co-operation Agreement and, by surgical diagnosis, treatment, and hospital care advised and signing below, agree to abide by it. supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the law of Ontario where the services are rendered, either at a doctors office or in a Student Signature: hospital. I expect to be contacted as soon as possible in this event. _________________________________ Date Signed: ___________________________ Signature of Parent/Guardian: ___________________________ Date signed: __________________