Waiver And Medical Release Form Page 2
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2Is there anything else we should know about your child/youth?____________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Precautions are taken for the safety and health of your child/youth, but in the event of
accident, sickness or death, Steinmann Mennonite Church, its staff, and its volunteers
are hereby released from any liability.
In the event that your child/youth requires special medication, x-rays or treatment, the
parents/guardians will be notified immediately.
In case of an emergency, I hereby give permission for the adults in charge to act on our
behalf to seek and approve medical assistance, and agree to cover the appropriate
costs.
Your child/youth must be covered by Provincial Health Insurance or equivalent medical
insurance.
Provincial Health Insurance Number (including version code) _____________________
Name of Family Physician __________________________________________
Phone number of Family Physician________________________
Name and Phone Number of Dentist _______________________________________
I/We hereby give my child/youth permission to participate in the activities of Steinmann
Mennonite Church and to travel with designated drivers to such events for the church
year September 1, _______ to August 31, _______.
Parent/Guardian’s Signature: ____________________________________________
Date: _______________________________________________________________
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