Form B: Medical Disclosure Form (Child) - Parks, Recreation And Culture Department (Page 2 of 2) in pdf

Form B: Medical Disclosure Form (Child) - Parks, Recreation And Culture Department Page 2

Does the participant have any allergies (include those to food, medication, environment)?

Does the participant have any allergies or sensitivity to sunscreen?

Circle one:

YES

Does the participant have any fears that leaders should be aware of (e.g. water, bees)?

Please list any family information or special instructions that the instructor should be aware of:

Signature of Parent/Guardian

Date

C. MEDICAL RELEASE:

In the event that my child _______________________ is injured, ill or in need of medical attention, I authorize

the City of Surrey staff or agents to seek medical attention and/or admit my child to hospital if I am unable to

be contacted or otherwise unable to respond.

Signature of Parent/Guardian

Date

D. PICK UP AUTHORIZATION:

The following individuals are authorized to pick up my child at the end of this class. My child will only be

released to the individuals listed below. Identification may be required.

_________________________________ ________________________________________

Authorized Person

Relationship to Child

_________________________________ ________________________________________

Authorized Person

Relationship to Child

_________________________________ ________________________________________

Authorized Person

Relationship to Child

Signature of Parent/Guardian

Date

B- White Form - Medical Disclosure (Child).docx

Form B: Medical Disclosure Form (Child) - Parks, Recreation And Culture Department Page 2