Online Youth Group Registration Form
Youth Name
First Name
Last Name
Are you legally allowed to make medical decisions in Canada?
Date of Birth
-
Month
-
Day
Year
Date
Province
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Grade Level
What are you struggling with?
What would you most like to develop? (social, stress management, anxiety management, etc)
Parent/Guardian Information
If you are not medically allowed to make decisions a legal guardian must be contacted for permission to attend group.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Acknowledgment
I agree to follow the guidelines, rules, and policies of the organization.
If a chaperone needed, I'll do that.
The repeated offense of the rules be the youth may result in suspension or expulsion.
Parent/Guardian registered in this form has legal custody over the child.
I allow my child/myself to be sent communications regarding attendance details and to confirm registration.
For medical emergencies, I allow the facilitator to call 911 to aid my child.
I release this organization from any and all liability from accident or injury to the child during the organization related events.
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: