• YW Calgary Mindful Moments Registration

    Please complete the following registration form and one of our team members will contact you shortly.
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    Pick a Date
    • First Sibling Start 
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    • First Sibling End 
    • Second Sibling Start 
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      Pick a Date
    • Second Sibling End 
    • Third Sibling Start 
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    • Third Sibling End 
    • First Parent/Guardian Start 
    • Second Parent/Guardian Start 
    • Emergency Contact Information 
    • Demographics - Based on the person being registered 

    • Accessability: Do you have any long-term (over 6 months)

    • Demographics:

      This information is collected under the authority of the Freedom of Information and Protection of Privacy Act (FOIP) Section 33(c) for the purpose of program evaluation and planning. The data will not be shared beyond The City of Calgary and the agencies that collected it, where it will be aggregated, analyzed and reported. The findings will be used to determine overall program effectiveness to improve services for all participants. Completion of demographic and survey data is voluntary. If you have any questions about the use of the information, please contact The City of Calgary at fcss.indicators@calgary and a Research Social Planner will respond.

    • YW Calgary Participant Impact Survey 1 

    • As a responsible organization, we want to fully measure the impact of our work with you. To do this we are inviting you to complete this short survey. Typically, it takes 3 to 5 minutes to complete. Your answers will not be connected to you in any way. You will not be named, and your answers will not be shared with staff or any third parties. Your answers will not affect your program participation now or in the future. If you have any question throughout the survey, please feel free to ask YW staff members and they will answer your question or direct you to someone who can. Thank you for your support.

    • Thank you for taking the time to answer our questions. The YW Calgary values your feedback!
      The results will help us to understand your needs, if they have been met and to provide better service. If you have any questions, comments, or concerns about the survey, please reach out to your program service provider.

       

    • Mindful Moments Acknowledgements & Consent 

    • Mindful Moments is a psycho-educational group program to support children in developing a mindful lifestyle. A mindful lifestyle means living with greater awareness, connection, and intention. Mindful Moments is not counselling or therapy. However, participants may find that they benefit most from the group experience if they share openly their own ideas and experiences. For those parents who would like more support, one-to-one coaching sessions with the group facilitators are available on an as-needed basis.

       

      Privacy & Confidentiality

      I understand that the information collected from myself and my child(ren) will be kept confidential under the Freedom of Information and Protection of Privacy Act (FOIP), Section 33(c) and will only be used for the purposes of this program.

      All personal information is stored in our secure client information database, Penelope. Any program reporting from this database is done in a way that does not identify you or your child(ren) as individuals. Further, we keep the information only for the length of time necessary to fulfill the purpose for which it was collected.

      I understand that the information I share is confidential and will not be released except if:

      ·         I provide written consent

      ·         there is risk of harm to me or others

      ·         abuse or neglect of a child or a dependent adult may be happening

      ·         there is a legal order that requires the release of information.

      For example, information to Calgary Police Service, RCMP, Child and Family Services, Probation /Parole, Alberta Health Services, Homefront Society, or your referral agency will not be released unless at least one of the above conditions is met.

      Information may be shared about me or my child(ren) with members of the Mindful Moments team. I understand that this would be done to provide the best services for me or my child(ren). I also understand that the information shared would be on a “need to know” basis.

       

      Child Protection Services Acknowledgement 

      In the event that YW Mindful Moments has reason to suspect the occurrence of physical, sexual, or emotional abuse, neglect, or exploitation of a child, YW Mindful Moments will, as required by the Child, Youth and Family Enhancement Act to report their concern to the local Child and Family Services Authority.

       

      First Aid Permission

      I hereby authorize staff at YW Mindful Moments to administer medical treatment and/or first aid for any minor injury or accident while my child is in their care.

       

      Emergency Care Authorization

      I give my permission for emergency care decisions to be made by YW Mindful Moments staff regarding my child/children in the event of any emergency that impedes regular program operations, and I shall be financially responsible for such advice and services.

       

      Assumption of Risk and Informed Consent

       Participation in the program has risks and hazards, I waive any and all claims for myself and child(ren) that I have or may have in the future against, and to release and discharge from any and all liability, the YW Calgary Mindful

      Moments, directors, managers, employees, agents, volunteers and representatives, and their respective successors and assigns, or any of them in connection with or participation in the YW Calgary Mindful Moments program and activities (collectively, the “Releases”), for any and all of the following:

      ·         Personal injury

      ·         Death

      ·         Property damage; and/or

      ·         Any other loss, damage or expense

       

      Grievance Procedure

      Your feedback is important to the Mindful Moments program, if you have any concerns or suggestions,

      please discuss it immediately with the Mindful Moments Supervisor. If the concern is not resolved at this level, you will be directed to contact the Manager, Child Development Services. This person will attempt to meet or speak with you within five working days. Please contact the program supervisor at (403) 250 7500.

       

      Program Consent

      I confirm that I have read and understand this agreement, I agree to be bound by its terms, and I am aware that by signing this agreement I am waiving certain legal rights against the YW Calgary Mindful Moments program including the right to sue or claim compensation following an accident.

      I also understand that by signing this agreement I consent for child(ren) to participate in the YW Calgary Mindful Moments program. I may withdraw consent for myself and/or my child(ren) at any time, for any reason and without prejudice.

    • I,   *   *   (parent/guardian) consent to my minor child(ren) named below;
      I,         (parent/guardian consent to my minor child(ren) name below;
      Child 1:         Child 2:         
      Child 3:         Child 4:         
      To participate in the YW Calgary's Mindful Moments program. I have read the information provided about the program and any questions I had have been answered to my satisfaction.

    • Clear
    • Clear

    • This consent was signed on   Pick a Date*   and is effective up to one (1) year from date of signing.

    • Mindful Moments Consent End 
    • Should be Empty: