Clive Baptist Church

Clive Soccer Camp July 19-21, 2024

• • Child's Name*
    First Name

    Last Name
  • Participant Birth Date*
    MM

    DD

    YYYY
  • Grade Entering in Fall 2024*
    >KindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6
  • Mailing Address
    Street Address

    Address Line 2

    City

    Province / State / Region

    Postal Code / Zip

    Antigua and BarbudaBahamasBarbadosBelizeCanadaCosta RicaCubaDominicaDominican RepublicEl SalvadorGrenadaGuatemalaHaitiHondurasJamaicaMexicoNicaraguaPanamaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesTrinidad and TobagoUnited StatesArgentinaBoliviaBrazilChileColumbiaEcuadorGuyanaParaguayPeruSurinameUruguayVenezuelaAlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandItalyLatviaLiechtensteinLithuaniaLuxembourgMacedoniaMaltaMoldovaMonacoMontenegroNetherlandsNorwayPolandPortugalRomaniaSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandUkraineUnited KingdomVatican CityAfghanistanBahrainBangladeshBhutanBrunei DarussalamMyanmarCambodiaChinaEast TimorIndiaIndonesiaIranIraqIsraelJapanJordanKazakhstanNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLebanonMalaysiaMaldivesMongoliaNepalOmanPakistanPhilippinesQatarRussiaSaudi ArabiaSingaporeSri LankaSyriaTaiwanTajikistanThailandTurkeyTurkmenistanUnited Arab EmiratesUzbekistanVietnamYemenAustraliaFijiKiribatiMarshall IslandsMicronesiaNauruNew ZealandPalauPapua New GuineaSamoaSolomon IslandsTongaTuvaluVanuatuAlgeriaAngolaBeninBotswanaBurkina FasoBurundiCameroonCape VerdeCentral African RepublicChadComorosCongoDjiboutiEgyptEquatorial GuineaEritreaEthiopiaGabonGambiaGhanaGuineaGuinea-BissauCôte d\'IvoireKenyaLesothoLiberiaLibyaMadagascarMalawiMaliMauritaniaMauritiusMoroccoMozambiqueNamibiaNigerNigeriaRwandaSao Tome and PrincipeSenegalSeychellesSierra LeoneSomaliaSouth AfricaSudanSwazilandTanzaniaTogoTunisiaUgandaZambiaZimbabwe

    Country
  • Parent/Guardian Name*
    First Name

    Last Name
  • Phone Number*
     
  • Parent/Guardian Email*
     
  • Alternate Emergency Contact Name*
    First Name

    Last Name
  • Emergency Contact Relationship to Participant*
  • Emergency Contact Number*
     
  • Allergies/Medical Conditions*
    This information is collected under the authority of the Freedom of Information and Protection of Privacy Act. The information you provide will be used solely to provide appropriate care for your child and/or to contact you in the event of an emergency.
    Does your child have any allergies or medical conditions we need to be aware of? (Please Explain)
    
    
    Yes

    No
  • Please Explain
  • Medication*
    Is your child bringing any medication with him/her? (antibiotics, ventilator, prescriptions, etc?)
    Please explain any instructions to staff regarding these medications. Staff are not permitted to administer medication. Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of? Please explain.
    
    Yes

    No
  • Please Explain
  • Alberta Health Care Number*
    In the event that your child requires professional medical treatment, we will attempt to notify you immediately. Please enter below participant's AHC number.
    Your child must be covered by Provincial Health Insurance or equivalent medical insurance.
    
  • Family Physician Name*
  • Family Physician Contact Number*
  • Liability Waiver*
    Your child will be cared for as if they were our child. Every precaution is taken for the safety and well being of your child. Even with normal activities there are certain risks involved. I understand and accept these potential risks, and, by checking the box below, I am bound to release forever Clive Baptist Church all the individuals associated with it, from any and all liability for injury or damage which may be sustained by the guardian and/or child of the guardian, or property of the same at or in transit to or from any church activity. In case of surgical emergency, Clive Baptist Church will use all means to contact the guardian on file for permissio required to transport, hospitalize, and secure proper treatment for the participant listed on this form. If the guardian listed onthis form is unreachable, I hereby give Clive Baptist Church permission to secure proper treatment.
    
    Yes
  • Parent/Guardian Full Name*
  • Photography*
    There will be a photographer on site to take pictures of soccer camp participants throughout the week of camp. Photographs from the camp may be posted on the Clive Baptist Church Website and Facebook page. Clive Baptist Church has permission to post photographs of my child registered on this form for Soccer Camp from July 19-21, 2024.
    Yes

    No
  • Inclement Weather*
    In case of inclement weather, notifications and cancellations will be posted on the Clive Baptist Church website only. Emails will not be sent out.
    www.clivebaptist.ca/events
    I have read and understand.
• 
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