OSSD Credit Granting Course Waiver **One waiver per student Student's Name * First Name Last Name Student Date of Birth * MM DD YYYY Student's Dietary Restrictions * (i.e no sugar, oily foods, etc) (if not applicable type, NA) Student Allergies * (if not applicable, type NA) Student Medications and/or Treatments * (if not applicable, type NA) Student Medical History * (i.e. surgeries, injuries, etc) (if not applicable, type NA) Physician Information Physician Name * First Name Last Name Physician Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Physician Phone * (###) ### #### Student's OHIP Number * (i.e. 0000 000 000 AA) Emergency Contacts Emergency Contact #1 Name * First Name Last Name Emergency Contact Number * (###) ### #### Emergency Contact Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact #2 Name * First Name Last Name Emergency Contact Number * (###) ### #### Emergency Contact Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Additional Authorized People (must be over 18, include name, address, phone number) (if not applicable, type NA) By signing this form, you are consenting to the taking of photographs and/or video recordings of your child or children by The Blue Marble Academy for the parents/guardians private blog, marketing, advertising, promotional, publicity and/or communication purposes. The photographs and/or videos might also be used by news media in promoting The Blue Marble Academy's programs & services. * Agree Disagree Thank You for sending in the PA Days Camp Waiver Form! We will send you an Invoice from Quickbooks within 24 Hours.
