Ridicuputt Permission Form

DATE: ! Thursday, May 22nd DROP OFF: !6:30 PM @ Fairview Mini-Putt, 285 Geneva St., St. Catharines PICK UP:! 8:30 PM @ Dairy Queen, 292 Geneva St., St. Catharines COST: ! $7.00 CONTACT: ! Mark Durksen if you have any questions: ! ! 905-937-6900 or markdurksen@hotmail.com OTHER INFORMATION: Ridicuputt is mini-putt... with a twist! After ridicuputting we will walk to Dairy Queen on Geneva St. for ice cream. Bring extra money if you would like ice cream. Will be outside for the evening so dress appropriately.
Name: _____________________________________________________ Phone #: _________________________________ Address: ___________________________________________ City: _________________________ Postal Code: ________ OHIP #: ____________________________________ Allergies: _________________________________________________ Medications being taken: ________________________________________________________________________________ Emergency Contact Person: _________________________________________ Phone #: ____________________________ Student Co-operation Agreement Were glad that youre coming mini-putting 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 miniputting with NEMBY at Fairview Mini-putt and then walk to Dairy Queen for ice cream. 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 - Be respectful to the facility and follow all Fairview Minipossibility of unforeseen hazards and know the possibilities of Putt rules and guidelines. risk. I agree not to hold Scott St. MB Church, Fairview MB - Do not be disruptive to other patrons. They are there to Church or Grantham MB Church or their employees or enjoy the facilities. - Respect the students and adult leaders you are with. If an volunteers liable for damages, losses or emergency. I hereby authorize an adult leader as agent for me, to consent to any Xadult leader tells you to do something, obey them. ray examination, medical, dental or surgical diagnosis, I have read the above Co-operation Agreement and, by treatment, and hospital care advised and supervised by a signing below, agree to abide by it. physician, surgeon or dentist (as appropriate) licensed to practice under the law of Ontario where the services are Student Signature: 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: ___________________________ ___________________________ Date signed: __________________