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Broadway Church Children's Ministry

Waiver and Medical Release Form for Events
Activity: Camp Wilderness VBS Kids Day Camp
Dates: Monday, March 19 to March 23, 2018 at Broadway Church
Time: 9am - 1pm For children Age 5 (kindergarten) - Age 12
Cost: $60 ( Lunch & T-shirt included)
(Early bird rate until Feb 28)
Cost: $75 after Feb 28

Name of Child *
Name of Child
Birthday *
Gender *
Address *
Parent/Guardian Phone *
Parent/Guardian Phone
Does your child have any severe/life threatening allergies? (Bee sting, food, penicillin, other)? *
Is your child bringing any medication with him/her? (Antibiotics, ventilator, Ritalin) *
Does your child have any physical, emotional, mental or behavioral concerns that our staff should be aware of? *
888Precautions are taken for the safety and health of your child but in the event of accident or sickness, Broadway Church, its staff, and volunteers are hereby released from any liability. In the event that your child requires special medication, x-rays or tretment, the parents/guardians will be notified immediately.***
Physician's Phone # *
Physician's Phone #
Emergency Contact
Emergency Contact
In case we can't reach Parent/Guardian
Emergency Phone
Emergency Phone
Declaration *
I/we the undersigned parent(s) or legal guardian(s) of the child listed above, declare that I/we voluntarily assume all risk or personal injury, loss of property, damage which may arise from participation in or attendance at these functions, including travel to and/from these functions, whether such injury, loss, or damage shall arise from negligence or otherwise. Broadway Church Children's Ministries upholds the standard that respect the rights and property of others. If this behavior cannot be maintained, the organization reserves the rights to withdraw the child from the program or withhold the right to participate in future events.