Child and Youth Registration Form

Child & Youth Registration Form
Name of the program you are registering for:
Name of Child
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Name 1
Relationship to child
Emergency Contact 1: Phone Number
Work Phone
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact 2
Relationship to child
Emergency Contact 2: Phone Number
Work Phone
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Does the child have any allergies?
If yes, please list
Does the child have any chronic illnesses?
If yes, please list
Does the child have any other medical conditions?
If yes, please list
Is there anything else we should be aware of?
Informed Consent & Acknowledgement
I hereby give my approval for my child's participation in any and all activities prepared by the R.M. of East St. Paul. In exchange for the acceptance of said child's candidacy, I assume all risk and hazards incidental to the conduct of the activities, and release and hold harmless the R.M. of East St. Paul and all its respective officers, agents, and representatives from any and all liability for injuries to child arising out of participating in selected program/activity.

In case of injury to child, I hereby waive all claims against the R.M. of East St. Paul, including all staff and affiliates, all participants, and, if applicable, owners of premises used to conduct the event.

I understand there is a risk of being injured that is inherent in all sports and recreational activities. Permission is also granted to the R.M. of East St. Paul and its affiliates including Directors, immediate staff, and coaches to provide the needed emergency first aid treatment required prior to the child's admission to the medical facility.

I understand that a refund for class will only be issued if the program is cancelled by the R.M. of East St. Paul or if give sufficient notice of 48 hours. The R.M. of East St. Paul will supply a refund in the event of medical emergencies with having received sufficient documentation.

I/We have read and understand the information presented in this packet. I/We are aware and understand that the activities included during the program involve inherent risks and may result in personal injury. I/We agree to cooperate with all program procedures and regulations. I/we are fully informed about the risks associated with participation in the activities and consent to our child's participation in the Recreation program.
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Photography Consent
Photography Consent I give permission to the R.M. of East St. Paul to take photos of above participant and to use the images for fundraising, publicity or other purposes to help achieve the programs aims. This might include (but is not limited to), the right to use them in printed and online publicity, social media, press releases and funding applications.

Yes I give permission to take photos
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Child & Youth Registration Form

Informed Consent & Acknowledgement

Photography Consent