Parent/Guardian Consent Form

Child's Name *

Date of birth *

Saskatchewan Health # *

Parent / Guardian full name *

Address *

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common.province

common.area

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Mobile Phone *

Allergies *

Specific dietary needs

Medical conditions

Current medications (please include dose and when it is taken/how often):

Has your child undergone any kind of medical procedure or surgery in the past 6 months? If yes, please describe the procedure and any limitations in order that we may accommodate certain needs of care for your child

Emergency contact details (if different from above)

First emergency contact (if different from above): please include name, relationship to child, telephone number

Second emergency contact (if different from above): please include name, relationship to child, telephone number

CONSENT (please read carefully) I agree to my son / daughter / child taking part in the activities of the Youth Wellness Camp. I confirm, to the best of my knowledge, that my son / daughter / child does not suffer from any medical condition other than those listed above. I consent to my son / daughter / child attending the Youth Wellness Camp in which the Yorkton Tribal Council will be hosting and all youth are participating in the events taking place. I consent to having my child’s medications kept locked safely by the camp Nurses. I consent to the care provided by Nurses as required, such as medication supervision, first aid and emergency responses. *

I give my consent

I do not consent

Signature of Parent / Guardian *common.clear

Signature - use of photoscommon.clear

Signature - assumption of risk and indemnity *common.clear

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Parent/Guardian Consent Form

Emergency contact details (if different from above)