LEAD Registration

Saint Columba House LEAD Program Registration

2025-2026
Group (For internal use only)
Registration Date

MonthDayYear
Date
YOUTH'S INFORMATION
Youth's Name*

First NameLast Name
Youth's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Birthday*

MonthDayYear
Date
Age (September 2024)
Mother tongue
Other languages spoken
School*
Grade (September 2024)*
TuesdayWednesdayThursday
PARENT/GUARDIAN'S INFORMATION
Name parent/guardian 1*
Cell number
Please enter a valid phone number.Format: (000) 000-0000.
Home number
Please enter a valid phone number.Format: (000) 000-0000.
Address if different than youth's
E-mail*
example@example.com
Name parent/guardian 2
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address if different than youth's
E-mail
example@example.com
EMERGENCY CONTACT

Must be someone other than a parent/guardian
Name*
Cell number
Please enter a valid phone number.Format: (000) 000-0000.
Home number
Please enter a valid phone number.Format: (000) 000-0000.
MEDICAL INFORMATION
Medicare card number:*
Expiry*
Since we will be serving meals every week, please describe any relevant medical or health information concerning your child that we should be aware of (including any allergies and food restrictions):*
Does your child have any learning, behavioral or social difficulties? If so please elaborate.*
Does your child have an intervention plan at school? If so please elaborate.*
YesNo
If yes, Name of medication
Reason for medication
YesNo
YesNo
AUTHORIZATIONS
AUTHORIZATION TO USE PUBLICITY MATERIALS
Saint Columba House may take pictures and/or use a video camera during some activities that my child will participate in. I authorize Saint Columba House to use this material in all or in part for publicity materials, including brochures, magazines, newspapers, web sites, etc. Children’s names will never be used in these publicity materials. All the material used will remain the property of Saint Columba House.
Signature parent or legal guardian

Clear
Date signed

MonthDayYear
Date
MEDICAL RELEASE
I authorize the staff of Saint Columba House to take the necessary steps in order to ensure the health and safety of my child in the case of an emergency. If the direction judges it necessary, I also authorize them to transport my child in an ambulance or otherwise, to a medical establishment. Moreover, if it is impossible to reach me, I authorize the doctor chosen by the staff to administer to my child any medical help required, including surgical intervention, injections, anesthesia and hospitalization.

I agree to accept full responsibility for all costs incurred by any of the staff of St Columba House in an emergency medical situation involving the treatment of my child. I understand that this may include charges for emergency transport, treatment, tests, professional fees, or any charges that medical personnel may levy.
Signature

Clear
Date signed

MonthDayYear
Date
Should be Empty:

Saint Columba House LEAD Program Registration

YOUTH'S INFORMATION

PARENT/GUARDIAN'S INFORMATION

EMERGENCY CONTACT

MEDICAL INFORMATION

AUTHORIZATIONS

AUTHORIZATION TO USE PUBLICITY MATERIALS

MEDICAL RELEASE