Program Registration 2020 - Limitless Youth Child's InformationChild's Name* First Last Child's Home Address*Child's Home AddressChild's Birthdate* Date Format: MM slash DD slash YYYY Child's BirthdateParent / Guardian Contact InformationMother / Guardian* Name Cell# Work# Mother / Guardian Address*AddressMother / Guardian Email* EmailEmergency Contact InformationEmergency Contact (Cannot be Mother or Father, must have a local address)Emergency Contact Name* Name Cell# Work# Emergency Contact Address*Emergency Contact AddressRelationship to childList of People allowed to Pick up your childAre there any immediate family members that should be denied phone calls with your child?Medication Required (epi pen, puffer, etc.)?* Yes No Medication Required TypeMedication Required TypeRelevant Health information (Medical Condition (s))?* Yes No List Medical Condition(s):List Medical Condition(s):Does your child have any pre-existing conditions that may present as influenza like symptoms? Ex: Allergies, chronic cough, etc.* Yes No List pre-existing Condition(s):List pre-existing Condition(s):Is Your Child Immunized?* Yes No Allergies?* Yes No Allergies please listInclusive care needed? (If Yes, interview required)* Yes No Please describe child's inclusive care condition/needsDietary restrictions please ListPlease list any other relevant Information:Please list any other relevant Information:Cultural Background:*Cultural Background:I agree* I agree:*1. I have been advised of the program activities and I am aware that there are certain risks inherent in my child's participation in the program activities. 2. I understand that every care and attention will be given to the health and comfort of the participant, and that the Fort McMurray Boys & Girls Club/Board and Staff cannot be held liable for any injuries sustained. 3. I hereby authorize the leaders of the program to secure medical advice and services, as they deem necessary, for the health and safety of my child; and I agree to accept financial responsibility for the costs greater than the benefits. 4. It shall be the discretion of the leader of the activity, as to what steps must be taken for the welfare and safety of the participant. Each program is a group living experience; members of each group are expected to participate fully in the program and to behave in the appropriate manner. Each child is given as much care and attention as possible, but the parents and the children must note that continuous disruptive behavior, which affects the enjoyment and safety of others, may result in the child being sent home. 5. I, the Parent/Guardian of the child do hereby agree to give the Fort McMurray Boys & Girls Club permission to take pictures of my child while participating in the various programs and activities at the Boys & Girls Club for the purpose of advertisement, promotion and publicity campaigns. What might include posting to the internet. I also agree to give the Fort McMurray Boys & Girls Club permission to take my child on supervised walking field trips off the property. 6. I give permission to release my child`s information to the Alberta Child and Family Services Licensing Officer for quality and licensing purposes. 7. I understand that my child is to be picked up at the end of the scheduled program time each day. (Your child must be signed out every day). If I do not adhere to this I understand that it will result in a $1.00 per minute charge for each minute that I am late. I fully understand all the information in this form, and I have discussed this carefully with my child. NOTE: NO REFUNDS WILL BE GIVEN. CAPTCHA
