/ Central Abbotsford Community School
P207 – 33355 Bevan Ave, Abbotsford, BC V2S 0E7
Phone 604-853-2221 Fax 604-855-4912

AFTER-SCHOOL PROGRAM - PERMISSION FORM

Please fill out form (2 pages) and return to the office of the school listed below:

Program: / Gourmet Cooking – Grade 6
Where: / Abbotsford Middle School, Cooking Room
When: / Tuesdays / May 31-June 21 / 2:30-4:00
Program Code: / 3961
Referred by: / Teacher’s Name:
Notes:
I give my permission for my child
to participate in the program listed above.

Personal Information

First Name: / Last Name:
Usual Name of Child: / Gender:
(if different)
Birth Date:
Address: / Date / Month / Year
Postal Code:
Parent or Guardian:
Relationship to child:
Home Phone: / Cell Phone:
Work Phone: / Email:
Emergency Contact:
Relationship:
Home Phone: / Cell Phone:
Work Phone:

Emergency Health Information

Care Card #:
Family Doctor: / Doctor’s Phone #:
Does the participant have any allergies?
Are there any physical or behavioural issues that the instructor should be aware of?

Medical Release / Parental Consent

I recognize that risk of injury or potential health risk may be involved in participation in the above-named program/activity. I hereby willingly assume such risk of injury, health risk, loss of life for myself or for the above-named person(s) for whom I am in law responsible and assume full responsibility during and after my/their participation in the program/activity.

In consideration of the acceptance of my application and the permission to participate in the program/activity, I, for myself, my heirs, executors, administrators, successors and assigns hereby release, waive and forever discharge the Central Abbotsford Community School Society, all other organizations, associations and companies associated with any of the programs offered by the Central Abbotsford Community School Society, and all their respective agents, employees, officials, servants, contractors, representatives, elected and appointed officials, successors and assigns of and from all claims, demands, damages, costs and actions whatsoever and however caused, arising or to arise by reason of my participation in the program or any of its associated activities.

By signing below, I have read, understood and agree with the preceding risk waiver. I understand the risks involved and I agree to allow the participation of my child in the program. In the event that my child is injured, ill, or in need of medical attention. I authorize the Central Abbotsford Community School Society staff to seek medical treatment and/or admit my child to the hospital on my behalf if I am unable to be contacted. I agree to incur all costs associated with the medical attention that my child receives.

Child’s name: / Parent/Guardian signature:

Photo Release

As the parent or legal guardian of the child listed above, I hereby give my consent to the employees of the Central Abbotsford Community School Society to photograph or film my child throughout the course of their program. I understand that these items may be used for newspaper articles, and CACS marketing (including flyers, website, Facebook, Twitter, etc.).

Child’s name: / Parent/Guardian signature:

Pick-Up

has my permission to walk home from this program for the duration enrolled.
child’s name
will be picked up from this program promptly at the end time while enrolled.
child’s name
also has my permission to pick up my child.
also has my permission to pick up my child.
Child’s name: / Parent/Guardian signature:
Date signed: / Parent/Guardian name:

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