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Please answer ALL THE following questions
1.) Does you child have any severe allergies?
(Bee
stings, food, penicillin, nuts, other drugs)
NO
YES If yes, please explain:
2.) Does you child have any life-threatening allergies?
NO
YES
If yes, please explain:
3.) Is
your child bringing any medication with him or her?
(Antibiotics, ventilator, Ritalin)
NO
YES
If yes, please explain:
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4.) Does
your child have any physical, emotional, mental or
behavioral concerns or
limitations that our staff should be
aware of?
NO
YES
If yes, please explain:
5.) How
would you rate your child’s swimming capability?
Able
to swim alone
Able
to swim with flotation device
Not
able to swim
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Precautions are taken for the safety and health of your child, but in the
event of accident or sickness, Laval Christian Assembly, its staff, and
its volunteers are hereby released from any liability. In the event that
your child requires special medication, x-rays or treatment, the parents/guardians
will be notified immediately. In case of surgical emergency, I hereby give
permissions to the physician selected by Laval Christian Assembly to
hospitalize, secure proper treatment for, and to order injection,
anesthesia or surgery for my child as named above. Your child must be
covered by Provincial Health Insurance (Medicare card must accompany child)
or equivalent medical insurance. |