YAAY Leadership Event

Medical & Emergency Information
Participant Name as it appears on their health card*

First NameLast Name
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name and phone number(s)*
Please put name & phone number(s) here
Back-up emergency contact (optional)
Name & phone number(s)
Health numbers

6 digit9 digit (Manitoba only)
If not covered by Manitoba or Ontario Health, list your health insurance provider

Insurance ProviderPolicy Number
Is the participant prescribed an inhaler or epi-pen? If yes, please explain any instructions. If not, type "no".*
Please be sure it is clearly labelled with their name.
Names and dosage of other medications that the participant will bring with them that need to be taken over the weekend:
Please only send the amount the participant needs for the weekend, and clearly label it with their name.
Will the above medications be:*

Self AdministeredAdministered by an adultN/A
If necessary, this participant may be given:

TylenolAdvilOther
Additional medical info, such as allergies, that a health care provider would need to know, if giving emergency treatment.

Informed Consent and Agreement of Participation

While every precaution will be taken for the safety and good health of participants, some sports and activities carry with them the inherent risk of personal injury. I understand that by allowing my child to participate in the activities of this supervised event, I am exposing my child to inherent risks and hazards. I accept all these risks and hazards and agree that by allowing my child to participate in these activities, I acknowledge that I will be responsible for any injury or other loss which may occur during my child's participation in these activities.

I, authorize the leaders, or their designate, to permit emergency treatment for my child if it is deemed necessary. (Efforts will be made to contact parent/guardian before treatment is given.)

I, parent/guardian, agree to hold blameless the Prairie to Pine Region of the United Church of Canada, its personnel, leaders and council from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of this event, as well as of any medical treatment authorized by the supervising individuals providing leadership at the retreat.

By clicking submit at the end of this form, I am acknowledging that I, the parent/legal guardian of the above named participant:
- am agreeing to allow the participant to attend this event, and
- have read and agree to the above statements, and
- state that any information given in the registration above is correct.

Registration Fees (on a pay what you can basis)

Volunteers will be preparing Saturday lunch and supper, we will prepare our own breakfast from foods provided, and we are sleeping on the floor! All this contributes to make our event affordable, but a small contribution from families who can afford to pay, would be helpful to cover the remainder. PLEASE NOTE: Choose the fee that works for you, but if you choose $0, please be mindful that by registering, you are still making a commitment to show up (unless you are unwell, and call to let us know). Food and activities will be planned for all registrants.
Please check which payment you can manage.*

$40.00$20.00$0
I prefer to pay by:*

Credit Card or PayPalE-transfer prairietopine@united-church.ca with a note "YAAY leadership event" (they have auto deposit)Cheque (hand in at the registration table upon arrival at the event)(Last Resort) Pay with cash at registration table upon arrival at eventN/A ($0)
Payment

prevnext( X )
CADEnter the appropriate amount
Anything else we need to know about this participant, that hasn't already been covered by any of the above (or won't be covered on the health form if bringing in a paper copy)?
Questions?

Contact Twila MacNair at tmacnair@united-church.ca or (204) 781-8124

Note: someone had the experience of being taken to a broken link when they hit submit. I did not get their registration. If anything seems odd when you submit, please confirm with Twila. We don't want to miss your registration!
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YAAY Leadership Event

Accessibility

Medical & Emergency Information

Registration Fees (on a pay what you can basis)