*Participants Name: |
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Full Address: |
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Phone: |
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*Email: |
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In Case of Emergency, I understand that every effort will be made to reach the
parent/guardian
or emergency contact listed on this form; but in the event one
cannot be reached, I hereby give
permission to secure medical treatment as
deemed necessary. I understand that all reasonable
safely precautions will be taken
at all times by the Diocese of Peterborough and its agents during
the events and
activities. I understand the possibility of unforeseen hazards and risks. I agree not
to hold the Diocese of Peterborough, its leaders, employees and volunteer
staff liable for damages,
losses, diseases or injuries incurred by the subject
of this form |
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| Parent / Guardian: I agree to the above statement
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| Participant: I agree to the above statement
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Statement of Consent |
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I hereby give permission for images of myself or my child, captured during regular and special activities leading up to and including BXVI 2012 Retreat through video, photo, and digital camera, to be used solely for the purposes of the promotional materials and publications and waive any rights to compensation or ownership thereto
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Participant: I agree to the above stated considerations and conditions
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Parent / Guardian if registrant is under 18 : I agree to the above stated
considerations and conditions
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Date of Birth : |
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Name of Parish: |
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School: |
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| In Case of Emergency Contact: |
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*Name: |
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Full Address: |
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Relationship to Applicant : |
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Phone : |
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Family Physician : |
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Physician Phone Number : |
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OHIP Number : |
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Please list any Allergies
and / or Medical Conditions : |
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| Chaperone Information |
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chaparone name: |
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chaparone phone: |
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chaparone email: |
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chaparone relation: |
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Cost is $60.00 before January 14th 2012, $70.00 as of January 15th 2012
With Online registration: Please make Cheques Payable to " R.C.E.C - BXVI "
and mail (or drop off) to:
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VEYO Centre
820 Frank Street
Peterborough, Ontario
K9J 4N4
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