{"id":901,"date":"2023-07-20T17:18:01","date_gmt":"2023-07-20T23:18:01","guid":{"rendered":"https:\/\/yfc.ca\/peace-country\/?page_id=901"},"modified":"2025-11-14T14:41:18","modified_gmt":"2025-11-14T21:41:18","slug":"room-27-youth-centre-waiver-form","status":"publish","type":"page","link":"https:\/\/yfc.ca\/peace-country\/room-27-youth-centre-waiver-form\/","title":{"rendered":"Room 27 Youth Centre Waiver Form"},"content":{"rendered":"\r\n\r\n<section class=\"y-chapter-banner  guten-block\">\r\n\t<div class=\"y-chapter-banner--bg\">\r\n\t\t<div class=\"y-chapter-banner--bg--overlay\"><\/div>\r\n\t\t<div class=\"y-chapter-banner--bg--img\" style=\"background-image: url(https:\/\/yfc.ca\/peace-country\/wp-content\/uploads\/sites\/51\/2020\/11\/chapter-banner.jpg);\"><\/div>\r\n\t<\/div>\r\n\t<div class=\"grid-narrow\">\r\n\t\t<div class=\"y-chapter-banner--inner\">\r\n\t\t\t\t\t\t\t\t\t\t<div class=\"y-chapter-banner--content\"><p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone  wp-image-896\" src=\"https:\/\/yfc.ca\/peace-country\/wp-content\/uploads\/sites\/51\/2023\/06\/room-27-logo-gradient-2-300x123.png\" alt=\"\" width=\"539\" height=\"221\" srcset=\"https:\/\/yfc.ca\/peace-country\/wp-content\/uploads\/sites\/51\/2023\/06\/room-27-logo-gradient-2-300x123.png 300w, https:\/\/yfc.ca\/peace-country\/wp-content\/uploads\/sites\/51\/2023\/06\/room-27-logo-gradient-2-1024x419.png 1024w, https:\/\/yfc.ca\/peace-country\/wp-content\/uploads\/sites\/51\/2023\/06\/room-27-logo-gradient-2-768x315.png 768w, https:\/\/yfc.ca\/peace-country\/wp-content\/uploads\/sites\/51\/2023\/06\/room-27-logo-gradient-2-1536x629.png 1536w, https:\/\/yfc.ca\/peace-country\/wp-content\/uploads\/sites\/51\/2023\/06\/room-27-logo-gradient-2-2048x839.png 2048w\" sizes=\"auto, (max-width: 539px) 100vw, 539px\" \/><\/p>\n<\/div>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\t<\/div>\r\n<\/section>\r\n\n\n\t<section class=\"y-gravity-form light-grey  guten-block\" >\r\n\t\t<div class=\"grid-narrow\">\r\n\t\t\t\t\t\t\t<h3 class=\"y-accordion--title y-color-responsive-text\">Room 27 Youth Centre Waiver Form<\/h3>\r\n\t\t\t\t\t\t<div class=\"y-gravity-form--inner\">\r\n\t\t\t\t<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_9' style='display:none'><div id='gf_9' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_9' id='gform_9'  action='\/peace-country\/wp-json\/wp\/v2\/pages\/901#gf_9' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_9_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_14'>Room 27 Youth Centre Waiver Form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_9_14' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Junior High (Ages 10-13)' >Junior High (Ages 10-13)<\/option><option value='Senior High (Ages 14-18)' >Senior High (Ages 14-18)<\/option><option value='Homework Help' >Homework Help<\/option><\/select><\/div><\/li><li id=\"field_9_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Participant Information<\/h2><\/li><li id=\"field_9_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Participant Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_2'>\n                            \n                            <span id='input_9_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_9_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_9_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_15'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_9_15' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy\/mm\/dd' aria-describedby=\"input_9_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_9_15_date_format' class='screen-reader-text'>YYYY slash MM slash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_15' class='gform_hidden' value='https:\/\/yfc.ca\/peace-country\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_41\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_41'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_9_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_3\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_9_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_9_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_9_3_1' id='input_9_3_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_9_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_9_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_9_3_2' id='input_9_3_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_9_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_9_3_3' id='input_9_3_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_3_4_container' >\n                                        <select name='input_3.4' id='input_9_3_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' selected='selected'>Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_9_3_4' id='input_9_3_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_9_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_9_3_5' id='input_9_3_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_9_3_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_9_16\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_16'>Parent\/Guardian&#039;s Number Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_9_16' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_6\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Parent\/Guardian Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_6'>\n                            \n                            <span id='input_9_6_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.3' id='input_9_6_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_6_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_6_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.6' id='input_9_6_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_6_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_5\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_5'>Parent\/Guardian Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_9_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_39\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_39'>Parent\/Guardian Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_39' id='input_9_39' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_9_8\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Emergency Contact Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_8'>\n                            \n                            <span id='input_9_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_9_8_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_9_8_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_23'>Relation to the Participant<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_9_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_9'>Emergency Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_9_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_17\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Medical Information<\/h2><\/li><li id=\"field_9_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_7'>Health Card Number of Participant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_9_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_20'>Family Doctor<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_9_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_22'>Any allergies or other concerns<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_9_22' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Additional Questions<\/h2><\/li><li id=\"field_9_25\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_25'>Does your Child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_9_25' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_26\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_26'>Please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_9_26' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_27\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_27'>Is your child bringing any medication with him\/her?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_9_27' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_28'>Please list them<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_9_28' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Consent<\/h2><\/li><li id=\"field_9_10\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Medical Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_10.1' id='input_9_10_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_10\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_10_1' >I agree<\/label><input type='hidden' name='input_10.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_10.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_10' tabindex='0'>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.<br \/>\n<br \/>\nI\/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.<\/div><\/li><li id=\"field_9_29\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Photos\/Media Release<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_29.1' id='input_9_29_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_29\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_29_1' >I agree<\/label><input type='hidden' name='input_29.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_29.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_29' tabindex='0'>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.<\/div><\/li><li id=\"field_9_30\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Communication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_30.1' id='input_9_30_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_30\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_30_1' >I agree<\/label><input type='hidden' name='input_30.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_30.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_30' tabindex='0'>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.<\/div><\/li><li id=\"field_9_31\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Purposes and Extent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_31.1' id='input_9_31_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_31\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_31_1' >I agree<\/label><input type='hidden' name='input_31.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_31.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_31' tabindex='0'>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\u2019s information, please contact us.<\/div><\/li><li id=\"field_9_32\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faith Disclosure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_32.1' id='input_9_32_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_32\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_32_1' >I agree<\/label><input type='hidden' name='input_32.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_32.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_32' tabindex='0'>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.<\/div><\/li><li id=\"field_9_33\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Parent\/Guardian Options<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_33.1' id='input_9_33_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_33\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_33_1' >I agree<\/label><input type='hidden' name='input_33.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_33.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_33' tabindex='0'>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.<\/div><\/li><li id=\"field_9_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Is the participant 18 years old or older?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_34'><li class='gchoice gchoice_9_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Yes, the participant is 18+ years old'  id='choice_9_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_34_1' id='label_9_34_1' class='gform-field-label gform-field-label--type-inline'>Yes, the participant is 18+ years old<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li 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);jQuery('#gform_ajax_frame_9').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_9');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_9').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_9').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_9').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_9').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_9').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_9').val();gformInitSpinner( 9, 'https:\/\/yfc.ca\/peace-country\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [9, current_page]);window['gf_submitting_9'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_9').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_9').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [9]);window['gf_submitting_9'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_9').text());}else{jQuery('#gform_9').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"9\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_9\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_9\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_9\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 9, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\t\t\t<\/div>\r\n\t\t<\/div>\r\n\t<\/section>\r\n\n\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_9' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Room 27 Youth Centre Waiver Form<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/peace-country\/wp-json\/wp\/v2\/pages\/901' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_9_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_14'>Room 27 Youth Centre Waiver Form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_9_14' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Junior High (Ages 10-13)' >Junior High (Ages 10-13)<\/option><option value='Senior High (Ages 14-18)' >Senior High (Ages 14-18)<\/option><option value='Homework Help' >Homework Help<\/option><\/select><\/div><\/li><li id=\"field_9_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Participant Information<\/h2><\/li><li id=\"field_9_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Participant Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_2'>\n                            \n                            <span id='input_9_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_9_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_9_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_15'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_9_15' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy\/mm\/dd' aria-describedby=\"input_9_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_9_15_date_format' class='screen-reader-text'>YYYY slash MM slash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_15' class='gform_hidden' value='https:\/\/yfc.ca\/peace-country\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_41\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_41'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_9_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_3\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_9_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_9_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_9_3_1' id='input_9_3_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_9_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_9_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_9_3_2' id='input_9_3_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_9_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_9_3_3' id='input_9_3_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_3_4_container' >\n                                        <select name='input_3.4' id='input_9_3_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' selected='selected'>Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_9_3_4' id='input_9_3_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_9_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_9_3_5' id='input_9_3_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_9_3_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_9_16\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_16'>Parent\/Guardian&#039;s Number Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_9_16' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_6\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Parent\/Guardian Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_6'>\n                            \n                            <span id='input_9_6_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.3' id='input_9_6_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_6_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_6_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.6' id='input_9_6_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_6_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_5\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_5'>Parent\/Guardian Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_9_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_39\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_39'>Parent\/Guardian Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_39' id='input_9_39' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_9_8\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Emergency Contact Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_8'>\n                            \n                            <span id='input_9_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_9_8_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_9_8_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_23'>Relation to the Participant<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_9_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_9'>Emergency Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_9_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_17\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Medical Information<\/h2><\/li><li id=\"field_9_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_7'>Health Card Number of Participant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_9_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_20'>Family Doctor<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_9_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_22'>Any allergies or other concerns<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_9_22' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Additional Questions<\/h2><\/li><li id=\"field_9_25\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_25'>Does your Child have any physical, emotional, mental, behavioural concerns or limitations that staff should be aware of?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_9_25' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_26\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_26'>Please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_9_26' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_27\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_27'>Is your child bringing any medication with him\/her?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_9_27' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_28'>Please list them<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_9_28' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_9_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Consent<\/h2><\/li><li id=\"field_9_10\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Medical Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_10.1' id='input_9_10_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_10\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_10_1' >I agree<\/label><input type='hidden' name='input_10.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_10.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_10' tabindex='0'>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.<br \/>\n<br \/>\nI\/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.<\/div><\/li><li id=\"field_9_29\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Photos\/Media Release<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_29.1' id='input_9_29_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_29\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_29_1' >I agree<\/label><input type='hidden' name='input_29.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_29.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_29' tabindex='0'>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.<\/div><\/li><li id=\"field_9_30\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Communication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_30.1' id='input_9_30_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_30\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_30_1' >I agree<\/label><input type='hidden' name='input_30.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_30.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_30' tabindex='0'>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.<\/div><\/li><li id=\"field_9_31\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Purposes and Extent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_31.1' id='input_9_31_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_31\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_31_1' >I agree<\/label><input type='hidden' name='input_31.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_31.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_31' tabindex='0'>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\u2019s information, please contact us.<\/div><\/li><li id=\"field_9_32\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Faith Disclosure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_32.1' id='input_9_32_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_32\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_32_1' >I agree<\/label><input type='hidden' name='input_32.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_32.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_32' tabindex='0'>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.<\/div><\/li><li id=\"field_9_33\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Parent\/Guardian Options<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_33.1' id='input_9_33_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_33\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_33_1' >I agree<\/label><input type='hidden' name='input_33.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_33.3' value='12' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_33' tabindex='0'>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.<\/div><\/li><li id=\"field_9_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Is the participant 18 years old or older?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_34'><li class='gchoice gchoice_9_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Yes, the participant is 18+ years old'  id='choice_9_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_34_1' id='label_9_34_1' class='gform-field-label gform-field-label--type-inline'>Yes, the participant is 18+ years old<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_35\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_35'>Participant Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_35' id='input_9_35_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_9_35_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_9_35' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/yfc.ca\/peace-country\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_9_35_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_9_35_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_9_35_data' name='input_9_35_data' value=''><\/div><\/li><li id=\"field_9_36\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_36'>Parent\/Guardian Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_36' id='input_9_36_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_9_36_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_9_36' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/yfc.ca\/peace-country\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_9_36_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_9_36_resetbutton' src='data:image\/png;base64,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' 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