Vineyard Community Center Summer Care

Enrollment Form 2009

Child Information
Name: / Date of Birth: / Gender: M or F / Age: / Grade completed:
K 1 2 3 4 5 / Preferred Name:
Address, City, State, ZIP:
Please list any allergies: / Who does the child live with?
Name: / Date of Birth: / Gender: M or F / Age: / Grade completed:
K 1 2 3 4 5 / Preferred Name:
Address, City, State, ZIP:
Please list any allergies: / Who does the child live with?
Name: / Date of Birth: / Gender: M or F / Age: / Grade completed:
K 1 2 3 4 5 / Preferred Name:
Address, City, State, ZIP:
Please list any allergies: / Who does the child live with?
Name: / Date of Birth: / Gender: M or F / Age: / Grade completed:
K 1 2 3 4 5 / Preferred Name:
Address, City, State, ZIP:
Please list any allergies: / Who does the child live with?
Parent/Guardian Information
Name(s):
Relationship to Child: / Day Phone: / Evening Phone:
Current Address: / Cell Phone:
City: / State: / Zip: / Status:
single married divorced other
Email Address:
Emergency Contact
Name (1):
Relationship to Child:
Day Phone: / Evening Phone: / Cell Phone:
Name (2):
Relationship to Child:
Day Phone: / Evening Phone: / Cell Phone:

MEDICAL INFORMATION AND WAIVER

EVENT: Vineyard Community Center Summer Care 2009

Do you have medical insurance? ____ Yes ____ No

Who is your medical carrier? ______ID Number ______

Does your child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition? ____ Yes ____ No

If yes, please explain: ______

In case of emergency, contact Dr. ______Phone: ______

I, the parent/legal guardian of the minor child(ren) participant(s) identified on this enrollment form, hereby authorize leaders, team members, supervisors and event staff as my agent to consent to medical, surgical, or dental examination and/or treatment of an emergency, and I hereby authorize treatment and/or care of any hospital. If there is an emergency and I cannot be reached, please contact either or both of the emergency contacts listed above.

Authorizing Signature of Parent/Legal Guardian: X ______

I acknowledge that I desire for the child(ren) listed above (collectively, whether one or more, the “Participants”) to participate in Vineyard Community Center Summer Care (including all activities related or incidental thereto), June 15 through July 3, 2009 and/or August 3 through 21, 2009 (collectively, the “Activity”). The Participants’ participation in the Activity is voluntary, and I agree to accept the risks of the Participants’ participation, including without limitation all risk of personal injury or death. In consideration for Vineyard Community Center permitting the Participants to participate in the Activity and to use its facilities and equipment, I agree on behalf of myself and my personal representatives and their successors in interest (all hereafter referred to as “releasors”) to release Vineyard Community Center and Vineyard Church of Columbus and their respective officers, trustees, directors, employees and agents (hereafter referred to as “releasees”) from all liability for any loss or damage and any claim for damages thereafter, on account of injury to my person or property, my death, injury to any Participant’s person or property, or any Participant’s death, whether caused by the negligence of releasees or otherwise arising directly or indirectly as a result of any Participant’s participation in the Activity. I further agree to indemnify and hold harmless each releasee for, and release each of them from, any loss, liability, damage or cost that releasees may incur due to Participants’ participation in the Activity, whether caused by the active or passive negligence of releasees or otherwise. I expressly agree that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Ohio and that, if any portion of the agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I have carefully read the above release and I know its contents. I am aware that this is a release of liability and I sign this voluntarily.

I release all officials and professional personnel from any claim whatsoever on account of first aid, treatment or service rendered to Participants during participation in the Activity. This release contains the entire agreement between the parties related to the subject matter hererof. The terms of this release are contractual and not a mere recital.

USE OF PHOTOGRAPHS: I do hereby grant and give Vineyard Community Center and Vineyard Church of Columbus the right to use each Participant’s photograph or image with or without my/our names, both single and in conjunction with other persons or objects for any and all purposes including but not limited to private or public presentations, advertising, publicity and promotion related hereto. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold Vineyard Community Center and Vineyard Church of Columbus harmless from and against any and all liability of whatever nature, which may arise out of or result from such uses.

SIGNATURE OF PARENT/LEGAL GUARDIAN (consenting to Participants’ participation under the foregoing terms and conditions):

X______Date: ______

(Submit completed form to Dawn Stickel, Vineyard Community Center)