Created to Create Registration

How many youth are you registering?*

Youth #1 Info

Please select your program*

Dive Into Drama (ages 10-15)
Stop Motion Animation (ages 9-13)

Name*

First Last

Date of Birth*

Gender*

Allergies or Medical Conditions

Other helpful information that may help your child thrive in the program

Youth #2 Info

Please select your program*

Dive Into Drama (ages 10-15)
Stop Motion Animation (ages 9-13)

Name*

First Last

Date of Birth*

Gender*

Allergies or Medical Conditions

Other helpful information that may help your child thrive in the program

Youth #3 Info

Please select your program*

Dive Into Drama (ages 10-15)
Stop Motion Animation (ages 9-13)

Name*

First Last

Date of Birth*

Gender*

Allergies or Medical Conditions

Other helpful information that may help your child thrive in the program

Youth #4 Info

Please select your program*

Dive Into Drama (ages 10-15)
Stop Motion Animation (ages 9-13)

Name*

First Last

Date of Birth*

Gender*

Allergies or Medical Conditions

Other helpful information that may help your child thrive in the program

Home Address

Address*

Street Address Address Line 2 City Province Postal Code

Parent/Guardian Info

1st Parent/Guardian Name*

First Last

1st Parent/Guardian Cell Phone*

1st Parent/Guardian Email*

Enter Email Confirm Email

2nd Parent/Guardian Name

First Last

2nd Parent/Guardian Cell Phone

2nd Parent/Guardian Email

Enter Email Confirm Email

Consents

PARTICIPATION*

Yes

I give permission for the youth(s) in my care noted above, to attend and participate in this program set forth by Northumberland Youth Unlimited and Northumberland Promise.

MEDICAL / PERSONAL HARM*

Yes

I give permission for the person(s) in charge to seek medical assistance for the youth(s) in my care noted above, in the event of accident or injury. Furthermore, I do not hold Northumberland Youth Unlimited and Northumberland Promise or any of their subsidiary programs responsible for any harm that may occur to the youth(s) in my care noted above, as a result of his/her wilful participation in the program.

AGE 10+ PERMISSION TO SIGN IN/OUT (optional)

Yes

I give permission to the youth(s) in my care noted above (age 10+) to sign him/herself in and out without a parent present. In doing so, I release Northumberland Youth Unlimited and Northumberland Promise of any responsibility after he/she signs out and leaves the premises.

PHOTO / VIDEO (optional)

Yes

I do authorize Northumberland Youth Unlimited and Northumberland Promise to take, use and own, in perpetuity; names, photographs or video/audio recordings of the youth(s) in my care noted above, understanding that these may be used for public promotional purpose. Northumberland Youth Unlimited and Northumberland Promise does not sell or give away any recorded materials or mailing list information.

Signature*

Registration Fees

Dive Into Drama – Youth 1

Price:

Stop Motion Animation – Youth 1

Price:

Dive Into Drama – Youth 2

Price:

Stop Motion Animation – Youth 2

Price:

Dive Into Drama – Youth 3

Price:

Stop Motion Animation – Youth 3

Price:

Dive Into Drama – Youth 4

Price:

Stop Motion Animation – Youth 4

Price:

Total

$ 0.00 CAD

Payment Info

Payment Method*

Credit Card*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Direct Debit Information*

Account Number Account Type Institution/Bank Account Holder Name

Please send your e-transfer to info@nyfc.org ASAP. Use the password “NorthumberlandYouth” and include a comment regarding “C2C Program Fee”.

Billing Address*

Same as home address

Street Address Address Line 2 City Province Postal Code

Current Programs

Registration

Youth #1 Info

Youth #2 Info

Youth #3 Info

Youth #4 Info

Home Address

Parent/Guardian Info

Consents

Registration Fees

Payment Info