March Break Camp 2018 Registration CHILD INFORMATIONLast Name*First Name*SexMaleFemaleNick NameDate of Birth Date Format: DD slash MM slash YYYY Booster Seat RequiredYesNoNAMES OF SIBLINGS AND THEIR BIRTHDATES:PARENT/ LEGAL GUARDIAN INFORMATIONFull Name(Mr./Mrs./ Ms./ Miss.)Full Name(Mr./Mrs./ Ms./ Miss.)Relationship to ChildRelationship to ChildAddress Street Address City ZIP / Postal Code Address Street Address City ZIP / Postal Code Home PhoneHome PhoneWork PhoneWork PhoneCell PhoneCell PhoneEmployerEmployerOTHER EMERGENCY CONTACT (Different from Parent/Legal Guardian)Full Name(Mr./Mrs./ Ms./ Miss.)Relationship to ChildWork PhoneHome PhoneCell PhoneAUTHORIZATION FOR PICK‐UPYour child will only be released to an authorized person listed on this form (parent/legal guardian and/or emergency contact). In case of an emergency or an unforeseen circumstance, please indicate the name, relationship, and phone number of any other person(s) who you authorize to pickup your child on your behalf.I have informed these individuals that they must present government issued photo ID each time they come to pick up my child. I understand that in case of an emergency, I will be the first one called. However, I also give my permission to OMAC to contact the following individuals AFTER contact has failed with parent designates on the first page of this registration form. Your children will not be allowed to leave the school with anyone not listed below. You can remove or add people to this list at any time by filling out the Change of Information form (available at your program site).Full Legal Name (as seen on government issued ID)RelationshipPhone NumberFull Legal Name (as seen on government issued ID)RelationshipPhone NumberFull Legal Name (as seen on government issued ID)RelationshipPhone NumberMEDICAL INFORMATIONDoctor's NameOffice PhoneAddress Street Address City ZIP / Postal Code Ontario Health Card #AllergiesMedical Problems, Conditions/DisordersOther Information we should know about your childEMERGENCY CONSENTIt is our policy to notify a parent when a child is ill or needs medical attention. Occasionally, we cannot contact a parent and need to get immediate help for your child. Our procedure is to take your child to the nearest emergency service. Please sign below so that we can take appropriate action on behalf of your child.I HEREBY GIVE MY/OUR CONSENT FOR MY/OUR CHILD WHEN ILL/INJURED, TO BE TAKEN TO THE NEAREST EMERGENCY CENTER BY OMAC STAFF WHEN I/WE CANNOT BE CONTACTED.I CONSENT TO AN AMBULANCE BEING CALLED TO TRANSPORT THE CHILD, IF NECESSARY.I FURTHER AGREE TO PAY ALL COSTS INCURRED FOR TRANSPORT.MARCH BREAK PAYMENT TERMSStart Date (DD/MM/YY) Date Format: DD slash MM slash YYYY Program Cost (inc. tax):Payment MethodCashChequeCredit Cardplease send check to:CC#Exp. Date Date Format: MM slash DD slash YYYY CV CodeName on Card:DAYS REQUIRED Monday Tuesday Wednesday Thursday FridayParent/Legal Guardian (Signature)Date Date Format: MM slash DD slash YYYY OMAC WORLD CLASS MARTIAL ARTS (signature)Date Date Format: MM slash DD slash YYYY PLEASE ALWAYS KEEP US UPDATED AND INFORMED OF ALL PERTINANT CON TACT, AND HEALTH CHANGESOMAC Participant Waiver of Liability & Media ConsentI, (Parent/Legal Guardian) of (Child) consent to have my child receive services from OMAC and am registering my child voluntarily. The consent will remain in effect for the duration of the program. I understand and agree to receive the program services delivered as part of the OMAC program that I have registered my child in. Programming activities such as recreation activities and outings (field trips) involve certain elements of risk. Injuries may occur while participating in these activities.ACKNOWLEDGEMENT The above named child has my permission to participate in program activities as planned by the OMAC program that I have registered my child in. I waive my legal rights against OMAC for any loss, injury or damage suffered during or by reason of participating in all events, programs and activities scheduled while my child is in the program. I authorize the application of emergency medical attention and undertake to be responsible for any hospitalization, medical expense and ambulance expense that may be incurred.Parent/Legal Guardian (Signature)Date Date Format: MM slash DD slash YYYY MEDIA RELEASE I, (Parent/Legal Guardian) give permission for (child) to appear in photographs, video and/or audio that may be used in the promotional materials of OMAC. My child’s image may be published or used in newspapers, promotional videos, television commercials, television news items, program brochures, poster, social media sites etc. or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by OMAC and/or external partners. No names will ever be used in association with a child’s image without written permission of the parent/guardian. By my signature as parent/legal guardian for (child)I give permission to OMAC to use any image taken during a OMAC program for any of the purposes as described above.Parent/Legal Guardian (Signature)Date Date Format: MM slash DD slash YYYY The OMAC Participants Waiver of Liability and Media Consent applies to OMAC March Break Programs for the 2018 school year. This iframe contains the logic required to handle Ajax powered Gravity Forms.