Participant Registration – Haliburton Highlands

Program Registration: The Bridge Youth Centre
Haliburton Highlands Youth Unlimited (HHYU) is collecting and retaining this personal information for the purpose of enrolling your child in our programs, to develop and nurture on-going relationships with you and your child, and to inform you of program updates and upcoming opportunities at our organization. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish to limit the information collected or to view your child’s information, please contact us.
Participant Name(Required)
First Last
Birth Date(Required)
MM slash DD slash YYYY
Age
Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone(Required)
Email(Required)
Does the student have any health concerns or accommodations needed:(Required)
- Physical
- Allergies (food related)
- Emotional or Mental
- Behavioural
- N/A
Please describe below any health concerns, medical conditions/allergies, or accommodations needed that we should be aware of:
Do you have someone else to register?(Required)
- Yes
- No

Consents and Releases
Purposes and Extent:(Required)
HHYU is collecting and retaining this personal information for the purpose of enrolling your child in our programs, to develop and nurture on-going relationships with you and your child, and to inform you of program updates and upcoming opportunities at our organization. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish to limit the information collected or to view your child’s information, please contact us.
Medical Consent:(Required)
I/we, the parents or guardians named above, authorize Haliburton Highlands Youth Unlimited (HHYU) to administer any first aid treatment necessary, and in the case of medical emergency, to authorize any physician or hospital to provide a medical assessment, treatment or procedures for the participant named above. HHYU representatives will do everything in their power to contact parents or emergency contacts before such action, if a problem should arise.
Responsibility:(Required)
I/we acknowledge that it is my responsibility to take the necessary steps for insuring against personal injury, property damage, or any loss by my child or by self. I also acknowledge that I must assume total responsibility for ALL medical coverage, accidental insurance and personal injury, or any other loss or damage. I will also pay for the cost to have my child sent home if he/she is unwilling to comply with the rules.
Faith Disclosure:(Required)
I/we understand that HHYU is a non-denominational, faith-based, not-for-profit organization that is governed and operated by Christian values, principles and beliefs. I/we understand that HHYU is inclusive to all participants regardless of their personal religious belief, race, sexuality, socio-economic status, or gender. I/we understand that the staff and volunteers of HHYU, with the utmost dignity and respect, may engage in discussions, conversations and/or lessons regarding topics of faith with my child during the course of their participation with HHYU and its affiliates.
Photos/Media Release:(Required)
I/we (do/do not) authorize HHYU to take, use and own, in perpetuity, names, photographs, or recordings of the students; understanding that these photos or recordings may be used for public promotional purpose (such as newspaper articles, newsletters, Facebook, other media outlets, etc.). HHYU does not sell or give away any recorded materials or mailing list information.
- Agree
- Disagree
Communication:(Required)
A policy is in effect that communications is to be used solely for the dissemination of information. I/we agree to permit HHYU staff or volunteers to communicate with applicant student via telephone, email, social media or text.
- Agree
- Disagree
Parent/Guardian Acknowledgement(Required)
By participating in this registration process and the corresponding activity, I/we, named below, undertake and agree to indemnify and hold harmless HHYU and KYFC, its trustees directors corporation members, servants, agents, volunteers, employees, and all program personnel from any and all actions, claims, and demands whatsoever whether existing as of this date or in the future; and, against any loss, damage or injury suffered by the participant as a result of being part of the activities of HHYU, as well as of any medical treatment authorized by the supervising individuals representing HHYU. This consent and authorization is effective only when participating in or travelling to events sponsored by HHYU.
Acknowledged
I have read, understood, and agree with the above and sign it to cover all the student activities associated with the Haliburton Highlands Youth Unlimited Program. (please type your written name and sign below)
Date Signed
MM slash DD slash YYYY
Signature(Required)

Step 1 of 3

Program Registration: The Bridge Youth Centre

Parent/Guardian/Caregiver Contact Information

Consents and Releases