Created to Create Winter 2024 Registration

How many youth are you registering?*

Youth #1 Info

Please select your program*

C2C Drama Club (ages 10-16) – Tuesdays in Port Hope
C2C Stop Motion Animation (ages 9-13) – Mondays in Cobourg

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*

C2C Drama Club (ages 10-16) – Tuesdays in Port Hope
C2C Stop Motion Animation (ages 9-13) – Mondays in Cobourg

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*

C2C Drama Club (ages 10-16) – Tuesdays in Port Hope
C2C Stop Motion Animation (ages 9-13) – Mondays in Cobourg

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*

C2C Drama Club (ages 10-16) – Tuesdays in Port Hope
C2C Stop Motion Animation (ages 9-13) – Mondays in Cobourg

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

MEDICAL / PERSONAL HARM*

Yes

I hereby release Northumberland Youth Unlimited from responsibility and liability for any harm that may occur to the youth in my care noted above, as a result of their wilful participation in the program/activity described above. I understand that reasonable precautions for the health and safety of participants will be taken. Furthermore, I give permission for the person(s) in charge to seek medical assistance for the youth in my care noted above, in the event of accident or injury, and acknowledge that I must assume total responsibility for any and all medical assistance related costs. Every attempt will be made to contact parents or guardians before such action.

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

Yes

I give permission to the youth in my care noted above (age 10+) to sign themselves in and/or out without a parent present. In doing so, I release Northumberland Youth Unlimited of any responsibility after they sign out and leave the premises.

Faith Disclosure

Yes

I understand that Northumberland Youth Unlimited is a faith-based charitable organization that is operated by Christian values. I understand that Northumberland Youth Unlimited is inclusive to all program participants regardless of their personal religious belief, race, sexuality, gender, or socio-economic status. I understand that the staff and volunteers of Northumberland Youth Unlimited, with the utmost dignity and respect, may engage in conversations and/or lessons regarding topics of faith with the youth in my care noted above, during the course of their participation with Northumberland Youth Unlimited.

PHOTO / VIDEO (optional)

Yes

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

PARTICIPATION*

Yes

I understand that the program/activity described above is a program of Northumberland Youth Unlimited and all consents on this page also apply to this program/activity. I have read, understood and hereby give permission for the youth in my care noted above, to attend and participate fully in the program/activity described above by Northumberland Youth Unlimited and agree to these waivers and conditions.

Signature*

Registration Fees

C2C Drama Club – Youth 1

Price:

C2C Stop Motion Animation – Youth 1

Price:

C2C Drama Club – Youth 2

Price:

C2C Stop Motion Animation – Youth 2

Price:

C2C Drama Club – Youth 3

Price:

C2C Stop Motion Animation – Youth 3

Price:

C2C Drama Club – Youth 4

Price:

C2C 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 Holder Name Account Number Account Type Institution/Bank Transit/Branch

Please send your e-transfer to info@nyfc.org ASAP and include a comment regarding “C2C Program Fee”. We use auto-deposit so please ensure your e-transfer is accurate.

Billing Address*

Same as home address

Street Address Address Line 2 City Province Postal Code