Acadia First Nation Youth Center General Information Sheets Name of Child: ___________________                                 D.O.B _________________ Address:  _____________________________________________________________   Parents Names: (Mother)  _____________       Telephone:  __________________                                                                                              Work:  __________________                                                                                                 Cell:  __________________                      (Father)  _________________      Telephone:  _________________                                                                                               Work:  __________________                                                                                                  Cell:  __________________  In a case, which you cannot be reached, please list 2 emergency contact names and numbers:  (1).  ________________________       Telephone:  _______________________ (2).  ________________________       Telephone:  _______________________   …………………………………………………………………………………………....................................……  Medical Information  Please list any allergies that your child has: (1)   __________________________  (2)  _________________________ (3)  _________________________   (4)  _________________________  Health Card Number:  _________________  Expiry Date:  _________________ (Please fill in this number, it is very important for us to have on file in case there is and emergency) Family Doctor:  __________________   Telephone:  ____________________   Please indicate any information that would help us understand your child better:  Example:  restrictions of exercises, limitations, do they have asthma or any other health problems, etc. ________________________________ ________________________________ ________________________________ Parent/Guardian Signature:  ___________________    Date:  __________________   Consent to Medical Treatment Should an incident arise whereby my child requires medial attention, the person or persons working at Youth Center shall attempt to contact me in order to obtain my consent regarding all medical treatment be carried out on my child.  Should it not be possible to contact me, I give the person or persons working at the Youth Center consent to any and all medical treatment for my child recommended as being necessary by a physician.  Parent/Guardian Names and Address and Numbers: ______________________________ ______________________________  I _______________(Parent’s name), give consent to medical treatment for my child, ________________ (child’s name) if an incident should arise in or during a Youth Center activity.  Should it not be possible to contact me, permission is granted to the Youth Center’s Employees and/or to the above person or persons, to follow through with any and all medical procedures for my child recommended by a physician.  Dated this _______ day of  ________, year of, _________. Signed ____________________  (Parent/Guardian)       TRANSPORTATION WAIVER OF LIABILITY    I, the parent/guardian of _______________, give him/her permission to attend the Youth event held by the youth center and it’s staff.   I understand that by signing this consent form absolves the Youth Center, and its staff members, from all liabilities arising from any error and/or omissions or actions planned or unplanned that may result in their injury, death or illness during their transportation to and from and while attending the Youth Center event under the supervision of it’s staff members.    MSI Number: ___________________________________   Doctor’s Name and Phone:  _________________________________   Any Allergies ___________________________________   Home Phone Number:  ____________________________   Emergency Contact Number:  ______________________________        _____________________              ___________________             Parent Signature                                          Date

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