ࡱ> LNK !jbjb (6yy8$A$6ee"HHH=6?6?6?6?6?6?69.<?6EH&"HHL?6H yy6H H H P^y8=6H H=6H H 45 m:55L60615<H <(5H 5HHH$ ?:   Medical/Emergency/Release Information Emergency Contact Name Emergency Phone Family Insurance Carrier ______________________________Policy #_____________________ If neither the authorized persons designated above nor I can be contacted in the event of an emergency, I authorize the adults in charge at the Film Club and Greater Clear Lake Families Exploring Down Syndrome program to contact the physician below at my expense for whatever treatment the attending physician recommends. I have notified The Film Club and Greater Clear Lake Families Exploring Down Syndrome of all medical and health conditions that my child has had or currently has. In the event of an emergency or if the physician designated below is not available, I hereby give permission for transportation to any medical facility or hospital and I authorize any qualified person or medical personnel to render necessary emergency medical care for my family and myself. (Please print the doctors full name below.) Name Office phone Fax/email Office address City State Zip Signed: ______________________________________ (Parent or Guardian)  Snacks: ۆ No assistance needed ۆ Some assistance needed ۆ Food needs to be cut/chopped ۆ Needs straw for liquids Mobility: (check all that apply) ۆ No assistance needed ۆ Requires assistance ۆ Walks with assistance ۆ Uses walker ۆ Uses braces ۆ Uses crutches ۆ Uses electric wheelchair ۆ Uses manual wheelchair List all mobility appliances that will accompany child to Film Club and Greater Clear Lake Families Exploring Down Syndrome (i.e., wheelchair, walker, etc.) ________________________________________________________________________________ Toileting:* ۆ No assistance needed ۆ Needs help transferring ۆ Needs help cleaning up ۆ Wears diapers/Depends during ۆ Day, ۆ Night *We may not be able to accommodate needs for children requiring intense toileting program. Is there any additional information we should know in order to care for your child? ____________________________________________________________________________________________________________________________________________________________________ Payment Information - A non-refundable deposit of $50 is required to register. Balance is due by _____________.. Consent to Attend & Participate I hereby give consent for my child to attend and participate in all programs and activities of The Film Club and Greater Clear Lake Families Exploring Down Syndrome. I understand and acknowledge that while the agents, servants, employees and/or volunteers may have received training on safety techniques, there are nevertheless risks associated with, and inherent in, my childs participation in the Film Club and Greater Clear Lake Families Exploring Down Syndrome programs and activities. I voluntarily choose to assume these risks and allow my child to attend and participate in all Film Club and Greater Clear Lake Families Exploring Down Syndrome programs and activities. I further consent to the Film Club and Greater Clear Lake Families Exploring Down Syndrome taking pictures, audio tapes and/or video tapes of my child participating in the Film Club and Greater Clear Lake Families Exploring Down Syndrome activities and programs and the Film Club and Greater Clear Lake Families Exploring Down Syndromes use of same in publications or publicity that is in the proper interest of the Film Club and Greater Clear Lake Families Exploring Down Syndrome. Release , Hold Harmless & Indemnity Agreement I RELEASE, HOLD HARMLESS and hereby agree to INDEMNIFY the Film Club and Greater Clear Lake Families Exploring Down Syndrome, its agents, servants, employees and/or volunteers from any and all liability, claims, causes of action or suits, for the loss or damage of property, or for injury to, or the death of, my child or others, for damages, losses, expenses, attorney fees, or costs of whatever nature sustained by me, my child or others, which may arise out of, or in connection with, my childs use or occupancy of the Film Club and Greater Clear Lake Families Exploring Down Syndromes premises or participation in Film Club and Greater Clear Lake Families Exploring Down Syndrome activities or programs, regardless of the nature or extent of such injuries, damages, costs, expenses, attorney fees or losses, or whether such injuries, damages, costs, expenses, attorney fees or losses are caused in whole or in part by the negligence or sole negligence of the Film Club and Greater Clear Lake Families Exploring Down Syndrome, its agents, servants, employees and/or volunteers, or caused in part by the negligence of the Film Club and Greater Clear Lake Families Exploring Down Syndrome, its agents, servants, employees and/or volunteers and the negligent or grossly negligent acts or omissions of my child or any other person or entity. This Release, Hold Harmless, and Indemnity Agreement is to be construed broadly, but it does not serve to release or waive claims or causes of action to which my child may be entitled due to personal injury. I understand the Film Club and Greater Clear Lake Families Exploring Down Syndrome in no way covenants the condition of any personal article or item of property upon the conclusion of any program session and that unnecessary valuables are not to be brought to the program. Signature of Parent/Guardian Date     PAGE  PAGE 1 Film Club is funded by a grant from United Way of Greater Houston Community Building Grant &'=>APQRS  " $ , 2 : D F H R X `bĸĸİߚۓۓߌ~vhnU]CJaJjhnU]UmHnHu hm<hnU] hxxhnU]hxxhnU]>*hnU]CJOJQJ^JaJhnU]CJaJhnU]CJOJQJaJhG/hnU]CJOJQJaJh*hnU]>*hnU] hnU]>* hG/hnU] h<hnU] hnU]5hG/hnU]5.&'RS X & D  %<gdnU] H%<gdnU] %<gdnU] 7$8$H$gdnU]gdnU] %gdnU]gdnU]DnJLd` ! 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Courier New;Wingdings"1hISIS h% 0!4d` 2QHP ?cv22008 Summer Registration Form Ted RickerlReverend Redbeard(        Oh+'0  (4 T ` lx' 2008 Summer Registration Form Ted Rickerl Normal.dotmReverend Redbeard2Microsoft Word 12.1.1@F#@)@) h ՜.+,0  hp  ' T. Rickerl%` 2008 Summer Registration Form Title  !"#$%&'()*+,-./0123456789:<=>?@ABDEFGHIJMRoot Entry Fr:O1Table<WordDocument(6SummaryInformation(;DocumentSummaryInformation8CCompObj`ObjectPool4r:4r: F Microsoft Word 97-2004 DocumentNB6WWord.Document.8