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NEMBY Jr.

Bowling Permission Form


DATE: ! Thursday, February 27th LOCATION:! Ina Grafton Gage Village ! ! 413 Linwell Rd., St. Catharines TIME:!! 6:30 PM to 8:30 PM COST: ! $5.00 CONTACT: ! Mark Durksen if you have any questions: ! ! 905-937-6900 or Mark@ScottStChurch.ca

Name: _____________________________________________________ Phone #: _________________________________ Address: ___________________________________________ City: _________________________ Postal Code: ________ OHIP #: ____________________________________ Allergies: _________________________________________________ Medications being taken: ________________________________________________________________________________ Emergency Contact Person: _________________________________________ Phone #: ____________________________

Student Co-operation Agreement Were glad that youre coming bowling 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: - Be respectful to the facility and staff and follow all facility rules and guidelines. - Respect the adult leaders and youth you are with. If an adult leader tells you to do something, obey them. - Ina Grafton Gage Village is a home for many people. Do not be disruptive to them. I have read the above Co-operation Agreement and, by signing below, agree to abide by it. Student Signature: _________________________________ Date Signed: ___________________________

Parental Permission I give my permission for the above named student to go bowling with NEMBY at Ina Grafton Gage Village. 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 possibilities of risk. I agree not to hold Scott St. MB Church, Fairview MB Church or Grantham MB Church or their employees or volunteers liable for damages, losses or emergency. I hereby authorize an adult leader as agent for me, to consent to any X-ray examination, medical, dental or surgical diagnosis, treatment, and hospital care advised and 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 hospital. I expect to be contacted as soon as possible in this event. Signature of Parent/Guardian: ___________________________ Date signed: __________________