Middlers & Bedlam

Sleepover

Tuesday January 3, 2017

7:00 PM Drop off in Sanctuary

Wednesday January 4, 2017

10:00 AM Pick Up in sanctuary

Grades 3-8

Cost $7

Max $20 per family from the same household

Register by:

December 18, 2016

Packing list c Sleeping bag c Air mattress

(optional, but we sleep on the floor) c Pillow c Pyjamas c Toothbrush c Toothpaste c Deodorant c Toiletries Do not bring: v Food – all food is provided. v Cell phones/IPod/electronic devices v Alcohol/drugs Note: all medication must be given to dee James, Edward white or Jacquie James upon arrival. Dee James 905.550.0532 deej@ stpaulsonthehill.com

Edward white 905.767.8383 edwardw@ stpaulsonthehill.com

Jacquie James 905.621.0155 jacquiejames@ stpaulsonthehill.com

St. Paul’s on-the-Hill Anglican Church

Appendix L Parent/Guardian Consent Form

Information Sheet

When we plan an event for your child/teen, not only do we want to plan a fun, exciting event, but we hold the health and safety of the participants as our primary concern. Part of that is to ensure that you know what your [son/daughter/ward] is doing, and if in the unlikely event we need to contact you in an emergency, we have that information at our finger tips.

Event Information:

The Event/Activity is: Middlers & Bedlam (grades 3-8)

to be held: January 3-4, 2017

at this location: St. Paul’s on-the-Hill Anglican Church

Cost: $7

Leader’s name: Dee James, Edward White & Volunteers

Transportation arrangements: N/A

Place of departure and return: N/A Participant Information:

Name: _____________________________________________________

(print name of participant attending event) £ Male £ Female

DOB (d/m/y): ___/___/______ Address: ___________________________________________________

City: _______________________ Postal Code: ________________

Student’s Cell #:___________________ Health Card #:________________________________________

Please list any allergies or dietary needs: ______________________________________________________

Does the participant carry and EPI-Pen? ? £YES £NO (ALL EPI-Pens must be carried on the student)

Please list any learning disabilities/behavioural challenges/emotional challenges (ie. Autism, ADHD,

anxiety, etc.) : _______________________________________________________________________________

__________________________________________________________________________________________

Does the participant take medication on a daily basis? £YES £NO

If so please list the medication the participant will bringing, the time the medication is to be administered

and the dosage: ____________________________________________________________________________

__________________________________________________________________________________________

** All medication must be sent in its ORIGINAL PACKAGE/CONTAINER and given to Dee James**

This information is extremely important in the event of an emergency. If the medication is over the counter please

clearly label it with the participant’s name on it. All medication will be kept and administered by Dee James due

to liability.

Continued on back

Responsible Ministry: Screening in Faith – Parental Consent Form | Revised April 2014

In return for permission to attend the above Event, the undersigned acknowledges and warrants that: a) My son/daughter/ward requires no special arrangements to safely participate in the Event under normal adult

supervision. £ Yes £ No If you answered No, specify the special arrangements required:

______________________________________________________________________________________

______________________________________________________________________________________

b) This consent form gives permission to seek whatever medical treatment is deemed necessary, and releases St. Paul’s on-the-Hill Anglican Church, its staff and volunteers of any liabilities. In the event of an emergency, if you cannot be reached, the emergency contact will be contacted. In the event that none of the contacts can be reached, a staff member of St. Paul’s on-the-Hill Anglican Church has permission to seek medical attention.

________________________________________ ________________________________ Signature of Parent/ Guardian Date £ Yes £ No I give permission to take the participant’s picture and video and to be used for promotion. The emergency contact information for your child/youth is...

Mother’ Name: ___________________________________________________________________________

Home Phone: (____) _____-_______ Cell Phone: (____) _____-_______

Father’s Name: __________________________________________________________________________

Home Phone: (____) _____-_______ Cell Phone: (____) _____-_______ If, in an emergency, you cannot be reached, the following people is hereby authorized to act your behalf and has been notified that he/she has been granted this authority and may be contacted by St. Paul’s on-the-Hill Anglican Church.

Must be different than above.

1. Name: ___________________________________________________________________________

Home Phone: (____) _____-_______ Cell Phone: (____) _____-_______

Relationship to Participant: __________________________________________________________

2. Name: __________________________________________________________________________

Home Phone: (____) _____-_______ Cell Phone: (____) _____-_______

Relationship to Participant: __________________________________________________________ Additional Information:

Permission form due: Sunday December 18, 2016

Do not bring: • Cell phones or electronic devices; all devices will be collected upon departure and returned when we return from

the trip. • Snacks: no food is permitted in the cabins. • Drugs or alcohol: prescription medication must be given to Dee James upon departure.