Summer Registration Form: 2023
Youth Information
Name
First Name
Middle Name
Last Name
Preferred First & Last Name?
Current Age
Date of Birth
/
Day
/
Month
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
Phone Number (Cell)
Please enter a valid phone number.
Phone Number (2)
Please enter a valid phone number.
Email
example@example.com
Alberta Health Number
Name of last school attended (including City and Province if outside of Edmonton)
Field Trip Concerns
Are there any places that you cannot participate at with regards to field trips? (In other words, are there any places where you are banned?)
Medical Information
Do you have any health concerns we should be aware of?
Diabetes
Epilepsy
Allergies
Epilepsy
Hemophilia
Asthma
Heart Condition
Other
Aboriginal Self-Identification
Please complete this section if you would like to declare your Aboriginal Status.
Select one of the following choices:
Please Select
Not Applicable
Metis
Inuit
Treaty Status
Non-Treaty
Treaty Status Number (optional)
First Nation/Band Name (optional)
Contact Information
What is the best way for us to contact you outside of school?
Please select the ways we can best reach you
Instagram
Facebook
Snap Chat
Email
Cell/Text
Landline (Home) Phone
Other
Best Email(s):
example@example.com
List Social Media Usernames:
Copyable Example: https://www.instagram.com/kmoorephotos/
Guardianship Status
**NOTE: If a youth declares DEPENDENT status they must have their legal guardian complete and provide a Guardian Consent Form.
I declare that I am INDEPENDENT, because:
I am 18 years of age or older.
I am 16 years of age or older but I do not live with my legal guardian(s).
I do not have a guardianship order (i.e., PGO) with a Social Worker.
I declare that I am INDEPENDENT, because:
I am 18 years of age or older.
I am 16 years of age or older but I do not live with my legal guardian(s).
I do not have a guardianship order (i.e., PGO) with a Social Worker.
I declare that I am DEPENDENT, because:
I am under 17 years of age.
I live with my legal guardian(s).
I have a guardianship order (i.e., PGO) with a Social Worker.
I declare that I am DEPENDENT, because:
I am under 17 years of age.
I live with my legal guardian(s).
I have a guardianship order (i.e., PGO) with a Social Worker.
IF you are a DEPENDENT:
I understand I must have my guardian complete a Guardian Consent Form.
Emergency Contacts
Only complete this section if you would like us to contact someone in the event of an emergency.
PERSON 1 - Name
First Name
Last Name
Relationship to Youth
Home Phone
Cell Phone
Email
example@example.com
PERSON 2 - Name
First Name
Last Name
Relationship to Youth
Home Phone
Cell Phone
Email
example@example.com
Group Home Info
Please complete this information if you currently live in a group home or shelter.
Name of Group Home/Shelter
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Fax Number
Key Contact Person
Email Contact Info
example@example.com
Recheck Consents...
Youth needs a signed Parent/Guardian Consent Form submitted? (A Guardian Consent Form is only required if the youth is a DEPENDENT)
YES — a Guardian Consent Form is required
NO — no Guardian Consent Form is required.
Youth has provided or declined Media Consent?
YES — I consent to be interviewed, filmed, or recorded by media outlets that have been invited by Inner City High School.
NO — I do not consent to be interviewed, filmed, or recorded by media outlets that have been invited by Inner City High School.
Youth and Confirmation of Registration?
YES — I require a letter confirming my registration. I agree to my attendance being shared with the recipient of this letter.
NO — no letter is required confirming my registration.
Declaration by Youth
I submit that the information provided in this document is true, correct and complete. Further, I recognize that it is my responsibility to notify Inner City Youth Development Association should the above information change.
Date
/
Month
/
Day
Year
Date
Youth Signature
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