Winter Middle School Program Registration Form

In-Person Middle School Program Registration Form

Winter Program 2023
Parental/Guardian Consent Form
Dear Parent/Guardian:

Citizens for the Advancement of Community Development (CACD) is very honoured to provide an innovative Fall Middle School Program for your child(ren). Our Fall Middle School Program is designed to equip your child/children with life skills through creative and enjoyable structured programming. These skills will be learned through integration with artistic activities.
Program Details:

January 16th - March 22nd, 2023

Weekly: In-Person on Monday and Wednesday

3:00 - 5:30pm

Location:

Mississauga Valleys Community Centre

1275 Mississauga Valley Blvd

Mississauga, ON L5A 3R8

Please take a moment to fill out the form below:
Parent/Guardian Name*

First Name Last Name
Participant Name*

First Name Last Name
I, {parentguardianName}, the parent/guardian of {participantName} give permission for my son/daughter to participate in the CACD Canada Fall Activities Program.
I hereby authorize CACD staff/volunteers to seek emergency medical attention for my child/children when necessary. Please initial:
My child's Health Card Number
I discharge CACD staff/volunteers of any liabilities in seeking medical attention for my child/children. Please initial:
I understand that the people who serve as facilitators are qualified/trained volunteers and professionals who have been carefully screened by the organization. I reserve the right to withdraw my child/children from the program at any time. I have read and understand the contents enclosed in this letter.
Parent/Guardian Signature*

Clear
Date*

MonthDay Year
Date
Intake Form - Participant Information
Date of Birth*

MonthDay Year
Date
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
EMAIL (Participant) *
example@example.com
PHONE #*
Gender*

MFOther
EMERGENCY CONTACT*
RELATIONSHIP*
PHONE NUMBER*
School*
Grade*
Media Consent Form

Please fill out as Parent/Guardian.
I hereby give Citizens for the Advancement of Community Development (CACD) permission to use photographs or any other visual media for public relations and promotion in any of the following communications and activities resulting from the afterschool program:
- Media Relations
- Annual Report
- Direct Main Materials
- Displays
- CACD Website
- CACD Newsletters
Phone Number (Parent/Guardian)
Email (Parent/Guardian)
example@example.com
Signature Parent or Legal Guardian

Clear
Date

MonthDay Year
Date
Should be Empty:

In-Person Middle School Program Registration Form

Parental/Guardian Consent Form

Intake Form - Participant Information

Media Consent Form