Section A
CHILD CARE
June 29, 2000 3:00 to 11:00 pm
July 1, 2000 2:00 to 1:00 am
Section B
Child's Name __________________________________________________________________Age __________ Sex __________ D.O.B* ______________
Child's Name __________________________________________________________________ Age __________ Sex __________ D.O.B* ______________
Child's Name __________________________________________________________________ Age __________ Sex __________ D.O.B* ______________
Child's Name __________________________________________________________________ Age __________ Sex __________ D.O.B* ______________
Child's Name __________________________________________________________________ Age __________ Sex __________ D.O.B* ______________
Child's Name __________________________________________________________________ Age __________ Sex __________ D.O.B* ______________
Section C
1.
F&CC WARRANTS THAT ALL PERSONNEL ARE CAREFULLY SCREENED PRIOR TO ASSOCIATION WITH F&CC.
2.
THE UNDERSIGNED PARENT/GUARDIAN, FOR HIMSELF OR HERSELF, AND HIS OR HER HEIRS, SUCCESSORS AND ASSIGNS HEREBY
RELEASES, ACQUITS AND FULLY DISCHARGES THE ASSOCIATION OF NIGERIAN PHYSICIANS IN THE AMERICAS AND MR. DAN
ODIGIE (MERRILL LYNCH), F&CC, THEIR RESPECTIVE SHAREHOLDERS, OFFICERS, DIRECTORS, AGENTS, EMPLOYEES,
REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS FROM ANY AND ALL CLAIMS, SUITS, SUMS OF MONEY,
JUDGEMENTS, EXECUTIONS, DAMAGES, LOSSES, KNOWN OR UNKNOWN CONTINGENT OR OTHERWISE, THAT PARENT, GUARDIAN
OR CHILD MIGHT HAVE, IN WHOLE OR IN CONNECTION WITH DIRECTLY OR INDIRECTLY, IN THE PROVISION OF CHILD CARE
SERVICES AND OR ANY USE BY PARENT/GUARDIAN OR THEIR CHILDREN AT SUCH FACILITY.
3.
PARENT, GUARDIAN MAY NOT BRING TOYS, JEWELRY, VALUABLES OR MEDICATIONS INTO CHILD CARE FACILITY. F&CC WILL NOT
BE RESPONSIBLE FOR SUCH ITEMS AND WILL NOT ADMINISTER MEDICATIONS OF ANY KIND.
4.
CHECK
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IF YOUR CHILD HAS NEEDS UNDER THE AMERICAN DISABILITIES ACT. F&CC WILL CONTACT YOU.
5.
THIS AGREEMENT SHALL BE INTERPRETED AND CONSTRUED UNDER AND IN ACCORDANCE WITH THE LAWS OF THE DISTRICT
OF COLUMBIA.
The children named above will be released ONLY to the person(s) signing this application.
Mother/Guardian Full Name __________________________________________________ Signature______________________________________________
Father/Guardian Full Name ______________________________ _____________________Signature______________________________________________
Address ___________________________________________________________________ City/State_____________________________________________
Daytime Phone _________ -_________-___________ Fax _______-_________-___________
Send check or fax credit card information to: ANPA, Inc., 6876 Indiana Ave., Suite F: Riverside, CA 92506
FAX : (909)778-0717
If registering by credit card, complete the following:
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MasterCard
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Visa
Card #__________ ___________ ___________ __________ Amount $________.___ Exp. Date _________
THIS CHILD CARE IS SPONSORED IN PART BY MR. DAN ODIGIE, CERTIFIED FINANCIAL MANAGER WITH MERRILL LYNCH. SPONSORSHIP
IS AVAILABLE FOR THE FIRST 30 CHILDREN TO REGISTER. ADDITIONAL CHILDREN WILL BE CHARGED FOR THE SERVICE. REGISTER
PROMPTLY TO RECEIVE THIS COMPLIMENTARY SERVICE. INCLUDE A REGISTRATION FEE OF ONLY $15/CHILD/DAY TO DEFRAY THE
COST OF MEALS.
ASSOCIATION OF NIGERIAN PHYSICIANS
IN THE AMERICAS, Inc.
6
TH
ANNUAL CONVENTION & SCIENTIFIC ASSEMBLY
Family & Child Care Registration/Consent Form
SPONSORED BY
Mr. Dan Odigie (Merrill Lynch) & ANPA, Inc.
Date
Check Days Required
Check In
Check Out
No. of Hours
No. of Children
Total
June 29, 2000
July 1, 2000
