Text Box:                           Noonan Syndrome Annual Conference                                                        Saturday, August 7th, 2010 (Grand Lodge Hotel)                                                            Time: 8h00-11h45 and 13h00-17h00              Children’s First and Last Name(s) 1. Name__________________________   Age ____    Language(s) spoken:_________________ 2. Name__________________________  Age ____    Language(s) spoken:_________________ 3. Name__________________________ Age_____   Language(s) spoken:________________   Please list only those allowed to check-out the above Child(ren) from the Kimberlee Care Children’s Program.   First and Last Name: ______________Relationship to Children):__________________________ First and Last Name: _____________Relationship to Child(ren):_____________________________   Are any of your children allergic to anything (foods, etc.) or taking medication? If yes, explain: (NOTE: Kimberlee Care staff does not administer or assist in the administration of any medications.) ______________________________________________________________________________________   ______________________________________________________________________________________   Do any of your children have health limitations or special needs? ______________________________________________________________________________________   ______________________________________________________________________________________   Noonan Syndrome Annual Conference We, the undersigned adults, agree to place our child or ward in the Kimberlee Care Children’s Program. For ourselves, our child/ward (or children/wards), and each of our respective heirs, assigns, and next of kin, do hereby release and agree to indemnify and hold harmless Kimberlee Care, and their respective officers, directors, agents, employees, assigns, vendors, and owners and/or lessors of the facility or facilities where the program is held (collectively “the Releasees”) from any and all claims which may now or hereafter arise from our child’s/ward’s (or children/wards) participation in the Kimberlee Care Program. We do not release claims arising from Releasees from any of their wilful misconduct or gross negligence.   We have read the above and understand this release. Furthermore, in the event of emergency or health concern, Kimberlee Care has our permission to administer first aid, contact our paediatrician or obtain emergency medical treatment for our child. We agree to pay all expenses incurred due to an emergency involving our child/ward.   Parent/Guardian Name: _________________________    Signature: __________________________      Date: _______­­­­________   Address: ________________________________________________________________________________   City: ____________________________            State / Prov: _______   Zip/Postal code:_________________   Country:_________________________: Work Phone: (____) _____________________________    Mobile Phone (____) _____________________ Email: _____________________________________________   Please mail filled out form with conference registration form Thank you!

 

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