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RELEASE FORM

Administration of Medication/Medical Treatment/Release

The undersigned, being the parent/legal guardian of a a participant in a Canadian Parents for French Alberta Branch (CPF Alberta) organized activity, do hereby request and authorize personnel or agents employed or contracted by CPF Alberta & NWT to provide necessary first aid and medical treatment to the said child, and for so doing, this will serve as a release and indemnification of and from any action or inaction of any personnel or agents of CPF Alberta & NWT associated with the rendering of first aid and administering of medical treatment to the said child. Further, the undersigned parent/legal guardian recognizes and acknowledges that the personnel and agents of CPF Alberta & NWT who may, as a result of this request, be rendering first aid or administering medical treatment to the said child, are not medical practitioners.

Event: Camping en francais: August 16 through till August 19, 2024

Dated in the Province of Alberta: December 21, 2024

 

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Medical Condition(s):

DO THIS IMMEDIATELY:

Medical Treatment:

Name of Medication(s):

Dosage

Method of Administration

Location of Medication

Administer within how many minutes?

If no relief

Possible side effect

N.B. For life-threatening reactions, call 911 for assistance. 


NOTES
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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