Action for Healthy Communities Spring Fling 2024
Participant Information
Youth name
*
First Name
Last Name
Youth date of birth
*
-
Month
-
Day
Year
Date Picker Icon
Youth gender
*
Female
Male
Prefer not to say
Other
Youth's current school
*
Example: Westmount
Youth's current grade
*
Example: Grade 9
Youth's address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation to youth
Youth resident status
*
Canadian Citizen
Permanent Resident (child has a PR Card)
Refugee Claimant
Other
Permanent Resident Information
Below is an example of what your permanent resident card looks like. Use your card to complete the required information.
Youth refugee claimant unique client number (UCI)
*
Youth permanent resident Number
*
Youth country of origin
*
Date Youth arrived in Canada
-
Month
-
Day
Year
Date Picker Icon
Youth's first language
*
Permissions
Consent (Consent should be made by the parent/guardian If the participant is under 18 years old)
Protecting Personal Information
AHC is committed to safeguarding the personal information provided by our clients. The personal information that you provide is collected for AHC purposes such as; activity enrolment, emergency contacts, AHC program assessment, funding reports and quality enhancement. Your collected information is not intended to be shared outside AHC without first obtaining your consent, unless obliged or permitted by law to disclose it. AHC keeps your information confidential, your information will be treated with the utmost care and discarded appropriately.
Photography & Media release
Photography & Media Release: I hereby give permission for me/my child/my projects/my child’s projects to be photographed/filmed by Action for Healthy Communities. I understand the photos/films will be used for promotion, sharing purposes and/or reports to our donors and for promotional purposes including flyers, brochures, newspapers, websites, and social media. I understand that although my child’s photograph/film/projects may be used for advertising, I do not expect compensation and that all photos/film/projects are the property of AHC and its affiliates.
Consent (Consent should be made by the parent/guardian IF the participant is under 18 years old)
*
I give consent
I do not give consent
Informed consent and waiver
I acknowledge that I am aware of, and accept the inherent physical risks and the other possible risks, dangers, and hazards associated with being a participant. These risks include but are not limited to all manner of injuries, broken, damaged or lost belongings and transmission of diseases (including Covid-19) in various ways and types from contact with other participants. I understand that Action for Healthy Communities (AHC) (employees, facilitators, and volunteers) are not responsible for any injury, loss or damage of any kind sustained by participants during the program or after the program day has ended. I understand that the rules and regulations are designed for the safety and protection of participants and hereby agree to follow /inform (my child) of the importance of abiding by the rules and regulations set down by Action for Healthy Communities.
Consent (Consent should be made by the parent/guardian if the participant is under 18 years old)
*
I declare that I've carefully read, understood and agreed to the contents of the above.
Parent/ Guardian Signature
Thank you for registration!
Please contact shelly.dunsford@a4hc.ca if you have any questions. You will receive an email within 5 business days about the status of your application.
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