Program Waiver – Moncton

Participant Information

Participant Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone*

Cell Phone*

Parent/Guardian Name

First Last

Parent/Guardian Work Phone*

Parent/Guardian Email*

Emergency Contact Name

First Last

Emergency Contact Phone*

Relation to the Participant

Medical Information

Health Card Number of Participant*

Family Doctor

Family Doctor Phone

Any allergies or other concerns

Additional Questions

Does your Child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of?*

Please explain*

Is your child bringing any medication with him/her?*

Please list them*

Consent

Medical Consent*

I agree

I/We authorize the administration of any first aid treatment necessary, and in the case of medical emergency, give permission to the Physician selected by the supervisors to hospitalize and secure proper treatment for my child as named above. Every effort will be made to contact parents or guardians before such action.

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.

Photos/Media Release*

I agree

I/We agree to permit reasonable use of photos, videos, written materials or other pictures of applicant student in promoting Youth for Christ/Youth Unlimited and their activities and programs. We understand that these could appear in agency newsletters, brochures, website or social media; or in local newspapers, on television, and might identify participants by first name. We wish to inform you of this in advance in order to avoid any surprises or misunderstandings.

Communication*

I agree

A policy is in effect that communication is to be used solely for the dissemination of information. I/We agree to permit YFC Canada staff or volunteers to communicate with applicant student via telephone, email, social media or text.

Purposes and Extent*

I agree

Youth for Christ/Youth Unlimited 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 YFC Canada/Youth Unlimited to limit the information collected, or to view your child’s information, please contact us.

Faith Disclosure*

I agree

I/we understand that Youth for Christ Canada is a non-denominational, faith-based, not-for-profit organization that is governed and operated by Christian values, principles and beliefs. I/we understand YFC 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 YFC, 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 Youth for Christ Canada and its affiliates.

Parent/Guardian Options*

I agree

I/we, named herein, undertake and agree to indemnify and hold harmless Youth for Christ/Youth Unlimited, Program Personnel, YFC Canada, its trustees, directors, corporation members, servants, agents, volunteers, employees and all program personnel from any and all actions, causes of 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 YFC Canada, as well as of any medical treatment authorized by the supervising individuals representing YFC Canada. This consent and authorization is effective only when participating in or traveling to events sponsored by YFC Canada.

Is the participant 18 years old or older?

Yes, the participant is 18+ years old

Participant Signature*

Parent/Guardian Signature*