Szczep Wigry Rejestracja na Rok Harcerski 2026-2027

Szczep Wigry - Roczna Rejestracja

Rok Harcerski 2026-2027
Participant Information
Full Name

First NameLast Name
Jednostka
Gender
Stopień
Participant is 18+
Participant's Email
example@example.com
Participant's Phone number (optional)
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Health Card Number
Participant's Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Parent/Guardian Information

Parent/Guardian #1 Details
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Parent #1 Email
example@example.com
I give my permission to share my email with KPH Mississauga so they can send me information about the activities (fundraisers, carpooling for trips, work weekends, etc.) being organized to support both Szczep Wigry and Szczep Wieliczka.
Parent/Guardian Information

Parent/Guardian #2 Details
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Parent #2 Email
example@example.com
I give my permission to share my email with KPH Mississauga so they can send me information about the activities being organized to support both Szczep Wigry and Szczpey Wieliczka.
Emergency Contact Details

Please specify who to contact in the event of an emergency if parents/guardians are unreachable
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Relationship to Participant
Permissions
I (the participant or parent/guardian if participant is under the age of 18) give permission for the participant to take part in the Polish Scouting Program – Szczep Wigry taking place from September 2026 to June 2027, including online and in person weekly meetings (“zbiórki”) in school facilities/church halls/outdoor parks, and additional activities at such other times and places as will be communicated as required. Description of activities involved: Activities involved in weekly meetings include games, singing, crafts, indoor and outdoor sports and training (pioneering, first aid, topography, field signaling, etc.). I give permission for the participant to take part in all activities, except for:
Please write N/A if none apply.
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I understand that the activities involve a certain degree of risk that could result in damage to person or property, injury or even death. After carefully considering the risk involved, and in view of the fact that Polish Scouting Association is a not-for-profit organization, I hereby release, hold-harmless and waive all claims associated with this activity which I may have against Polish Scouting Association in Canada and Polish Scouting Association in Canada (Ontario) Inc., and their employees, officers, directors, agents, volunteers and members. I further understand that photographs and or videos may be taken during this scouting activity by the organizers, and the resulting images may be used in the Association’s brochures and promotional materials including the Association’s electronic media, without further notice to me, and I consent to such use. I understand that, in the event my child is sent home due to a violation of the standards of conduct, I will bear all costs of the transport home and I acknowledge that I will receive no reimbursement of any fees. Participant's or parent's/guardian's signature (if participant is under the age of 18)
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Health Form
List any allergies such as food, insect stings, drugs, etc. Clearly explain asthma symptoms. If reaction is severe, please make certain that the severity of the reaction is clearly indicated. If more space is required to explain the medical concern, please attach the explanation below.
Does the participant have any allergies or asthma?
Allergies:
Please write N/A if none apply.
Dietary Restrictions: List any foods the participant should not eat for medical reasons. If foods are life threatening, explain the symptoms.
Please write N/A if none apply.
Medical Conditions: Please check off any life threatening conditions, physical limitations or any other concerns which might affect participation in the program.
Epilepsy
Migraines
Nosebleeds
Digestive Upsets
Sleepwalking
Diabetes
Bleeding Disorder
Bed Wetting
Fainting Spells
Chronic Ear, Nose, Throat Infections
Urinary Infections
Medic Alert Info
Medic alert for:
Please write N/A if none apply.
Other: Please Specify
Details for usual treatment
Please write N/A if none apply.
Mental/Psychological/Developmental Disorders : Please Specify (If Applicable)
Please write N/A if none apply.
Medication (information required for overnight trips - The medication being carried by the participant will be monitored by an Instructor)
If necessary, may over-the-counter medications be administered to relieve minor discomfort, fever, and/or colds (i.e. Tylenol, Advil, Benadryl, cold syrup)?
Has the participant received a Tetanus shot in the last 10 years?
Date of last Tetanus shot:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
In case of severe or life threatening medical condition, please upload a physician's permission to take part in scouting activities.

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In the event that medical care is required I understand that every effort will be made to contact me. I acknowledge that in the case of an emergency, medical treatment may be sought by an Instructor and/or provided by health care practitioners without my consent. I hereby authorize the Scouting Instructors to secure such medical advice and services as may be required for the health and safety of myself or my child (or ward). I agree to accept financial responsibility in excess of the benefits allowed by my Provincial Health Plan and to reimburse Szczep Wigry for medical prescriptions purchased for my child. Participant's or parent's/guardian's signature (if participant is under 18):
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Payment Details and Form Submission
I wish to pay via Interac e-Transfer and confirm that payment was sent at the same time that I completed this form.
Additional Comments:
Participant's or parent's/guardian's signature (if participant is under the age of 18):
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Once you click submit, you will be emailed a copy of your response. You may use the link in that email to modify your response if needed.

Please submit payment either in cash or cheque to the Szczepowy or Druzynowy. E-Transfers can be sent to wigry@zhp.ca and cheques are to be written out to "PSA – ZHP Szczep Wigry”.

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Czuwaj!

Szczep Wigry
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Szczep Wigry - Roczna Rejestracja

Participant Information

Parent/Guardian Information

Parent/Guardian Information

Emergency Contact Details

Permissions

Health Form

Payment Details and Form Submission