NEMBY Jr.

Swimming Permission Form

DATE: ! Thursday, January 30th LOCATION:! Brock University Aquatic Centre ! ! 500 Glenridge Ave., St. Catharines TIME:!! 6:30 PM to 8:30 PM COST: ! $3.00 CONTACT: ! Mark Durksen if you have any questions: ! ! 905-937-6900 or Mark@ScottStChurch.ca OTHER INFORMATION: Bring a bathing suit and towel.

Name: _____________________________________________________ Phone #: _________________________________ Address: ___________________________________________ City: _________________________ Postal Code: ________ OHIP #: ____________________________________ Allergies: _________________________________________________ Medications being taken: ________________________________________________________________________________ Emergency Contact Person: _________________________________________ Phone #: ____________________________

Student Co-operation Agreement Were glad that youre coming swimming with us and we hope that youll have a great time. To keep things enjoyable for everyone, there are a few simple guidelines to remember and live by:

Parental Permission I give my permission for the above named student to go swimming with NEMBY at the Eleanor Misener Aquatic Centre at Brock University. I understand that all reasonable safety precautions will be taken at all times by NEMBY youth leaders - Be respectful to the facility and staff and follow all facility during the event described above. I understand the possibility of unforeseen hazards and know the possibilities of risk. I rules and guidelines. - Respect the adult leaders you are with. If an adult leader agree not to hold Scott St. MB Church, Fairview MB Church or Grantham MB Church or their employees or volunteers liable tells you to do something, obey them. - Other people will be using the pool too. Help them have a for damages, losses or emergency. I hereby authorize an adult leader as agent for me, to consent to any X-ray good time by showing them proper respect. examination, medical, dental or surgical diagnosis, treatment, I have read the above Co-operation Agreement and, by and hospital care advised and supervised by a physician, signing below, agree to abide by it. surgeon or dentist (as appropriate) licensed to practice under the law of Ontario where the services are rendered, either at a Student Signature: doctors office or in a hospital. I expect to be contacted as soon as possible in this event. _________________________________ Signature of Parent/Guardian: Date Signed: ___________________________ ___________________________ Date signed: __________________