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 **Contact and Medical Information**
The personal information is collected to be used in the event of a medical emergency in the Regional Field House program(s).
Does your child have any allergies?
Does your child take any medications?
Does your child have any other pertinent medical information, restricted activities, or behavioral 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 parks and other facilities, indoor/outdoor games and activities, playing on playground equipment, and swimming. 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. contracts a commercial bus transportation service for all in-town of out-of-town field trips when scheduled. 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. *I agree that the Nustadia Recreation Inc. or its employees, servants or agents 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. 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. 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. The option to have older children sign themselves out this summer is not available. 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: 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
Darial Poxon, Programs & Special Event Director for Nustadia Recreation Inc,
at 587-757-0338 ext 305 or firstname.lastname@example.org Submit