BoothUniversityCollege

Booth UC Belong

Parental Release FormPage 1

Booth UC Belong

February 2- 3, 2018

Parental Release Form

BoothUniversityCollege, 447 Webb Place, Winnipeg, MB R3B 2P2
Phone: 204 – 947-6701 Fax: 204 – 942-3856

PLEASE NOTE: Before you can participate inBooth UC Belong, this form must be completed, signed and returned to Booth University College.

Student Information
First Name / Provincial Health Card No.
or equivalent
Last or Family Name / Additional Insurance – Policy Number
Home Phone # / Gender
Male Female
Age
Emergency Information
Parent(s) or Guardian(s) Names / Other Emergency Contact
Address / Address
Home Phone # / Home Phone #
Work Phone # / Work Phone #
Cell Phone # / Cell Phone #
Physician / Physician’s Phone #
Special Conditions
Identify any special needs or conditions that your child has

The Salvation Army and The Salvation Army William and CatherineBoothUniversityCollege place the highest value on the safety of our students and guests. The University College will make every effort to ensure the safety of participants in Booth UC Belong.

In exchange for the opportunity for my child to participate in Booth UC Belong, facilitated by Booth University College, I agree that:

  1. The parent(s) or guardian(s) submitting this application are those having legal custody of the child.
  2. Every precaution is taken for the safety and good health of participants in Booth UC Belong, but in the event of an accident or illness, I hereby release The Salvation Army and The Salvation Army William and Catherine Booth University College, its staff, employees and volunteers from all claims, demands, right of action, causes of action, present or future, whether the same be known, anticipated or unanticipated. I and my successors will not sue or bring other legal action against The Salvation Army or The Salvation Army William and Catherine Booth University College or any of its agents, employees or volunteers for any personal injury, property damage or loss as a result of participation in Booth UC Belong, whether or not occasioned by a perceived negligence of The Salvation Army or The Salvation Army William and Catherine Booth University College or any of its agents, employees or volunteers.
  3. In the event that your child requires medical attention or transportation, the parents/guardians will be notified immediately and will be responsible for any additional expense.
  4. In the event of a medical emergency, I hereby give permission to the physician selected by the College to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child named on this application.
  5. I acknowledge that I have valid provincial or equivalent medical coverage for the child.
  6. I give permission to The Salvation Army William and CatherineBoothUniversityCollege to use any photograph or video footage my child is in for UniversityCollegepromotional purposes.

I have read carefully this agreement, fully understand its contents and voluntarily sign it to give permission for my child named above to participate in Booth UC Belong, intending to be legally bound.

Parent’s/Guardian’s Name:
Parent’s/Guardian’s Signature:
Date: