Fall 2023 Middle School Program Registration Form

In-Person Middle School Program Registration Form

Fall Program 2023
Parental/Guardian Consent Form
Citizens for the Advancement of Community Development (CACD) is a youth-focused, Registered Charitable Organization dedicated to transforming the lives of BIPOC youth between the ages of 10 and 24. Since 2002, CACD has worked with the communities to transform the lives of youth through programming that:
- serves their unique needs,
- develops leadership capabilities, and,
- fosters civic participation
Parent/Guardian Name*

First NameLast Name
Program Details:

September 11th - December 13th, 2023

In Person Mondays and Wedndesdays

3:30 pm - 5:30 pm

Location:

Mississauga Valleys Community Centre

1275 Mississauga Valley Blvd

Mississauga, ON L5A 3R8

Please take a moment to complete the form below:
Participant Name*

First NameLast Name
I, the parent/guardian, give permission for my son/daughter to participate in the CACD Fall Middle School Program.

I acknowledge that the facilitators are qualified/trained volunteers and professionals who have been carefully screened by the organization. I reserve the right to withdraw my child from the program at any time. I have read and understand the contents enclosed in this letter.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Intake Form - Participant's Information

Please fill out the information below
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

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

MaleFemaleOther
EMERGENCY CONTACT*
RELATIONSHIP*
PHONE NUMBER*
School*
Grade*
How did you find out about this program?*

Friend/RelativeFlyerReferralSocial Media
If referred by someone, please provide their name
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 this program: Media Relations/Social Media Annual Report

CACD Websites CACD Newsletters
Phone Number (Parent/ Guardian)*
Email (Parent/ Guradian) *
example@example.com
(Signature of Parent or Legal Guardian)*

Clear
(Date)*

MonthDayYear
Date
Should be Empty:

In-Person Middle School Program Registration Form

Parental/Guardian Consent Form

Intake Form - Participant's Information