Formulaire de demande P.R.O. Jeunesse Application Form

P.R.O. KIDS APPLICATION FORM

Please refer to the upper right corner to select the language of your choice.
IMPORTANT
- P.R.O. Kids Edmundston is accessible only to Edmundston residents aged 18 or under.
- Requests are processed on a first come, first served basis.
- This confidential service is offered by P.R.O. Kids Edmundston and the Edmundston Recreation and Sports Department.
- P.R.O. Kids Edmundston gives itself a period of 4 to 6 weeks to study your request.
- It is important that you send your request atleast 6 weeks before the start of registration for the chosen activity.
Have you ever benefited from the services of P.R.O. Kids Edmundston?*

YesNo

Child Information
1st child
Name*

First Name Last Name
Date of Birth *

DayMonthYear
Medicare Number*
Sex*

MaleFemale
What kind of help are you asking for?*

RegistrationEquipment
Indicate your FIRST choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Indicate your SECOND choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Would you like to add another child to the application?*

YesNo

Child 2
Name*

First Name Last Name
Date of Birth *

DayMonthYear
Medicare Number*
Sex*

MaleFemale
What kind of help are you asking for?*

RegistrationEquipment
Indicate your FIRST choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Indicate your SECOND choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Would you like to add another child to the application?*

YesNo

Child 3
Name*

First Name Last Name
Date of Birth *

DayMonthYear
Medicare Number*
Sex*

MaleFemale
What kind of help are you asking for?*

RegistrationEquipment
Indicate your FIRST choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Indicate your SECOND choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Would you like to add another child to the application?*

YesNo

Child 4
Name*

First Name Last Name
Date of Birth *

DayMonthYear
Medicare Number*
Sex*

MaleFemale
What kind of help are you asking for?*

RegistrationEquipment
Indicate your FIRST choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Indicate your SECOND choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Would you like to add another child to the application?*

YesNo

Child 5
Name*

First Name Last Name
Date of Birth *

DayMonthYear
Medicare Number*
Sex*

MaleFemale
What kind of help are you asking for?*

RegistrationEquipment
Indicate your FIRST choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Indicate your SECOND choice of activity.*
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Would you like to add another child to the application?*

YesNo

Child 6
Name*

First Name Last Name
Date of Birth *

DayMonthYear
Medicare Number*
Sex*

MaleFemale
What kind of help are you asking for?*

RegistrationEquipment
Indicate your FIRST choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Indicate your SECOND choice of activity.*
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Would you like to add another child to the application?*

YesNo

Child 7
Name*

First Name Last Name
Date of Birth *

DayMonthYear
Medicare Number*
Sex*

MaleFemale
What kind of help are you asking for?*

RegistrationEquipment
Indicate your FIRST choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Indicate your SECOND choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Would you like to add another child to the application?*

YesNo

Child 8

If you want to add an other child, please complete de current request and submit a separate one.
Name*

First Name Last Name
Date of Birth *

DayMonthYear
Medicare Number*
Sex*

MaleFemale
What kind of help are you asking for?*

RegistrationEquipment
Indicate your FIRST choice of activity. *
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Indicate your SECOND choice of activity.*
If it is not there, please select "other", and fill the blank
Indicate the cost of the activity
Would you like to add another child to the application?*

Yes (please fill out a new application)No

Consent and submission
The applicant releases the municipality of Edmundston, the Edmundston Recreation and Sports Department, P.R.O. Kids Edmundston, their agents, mandataries and employees against all actions, procedures, claims, costs, damages, expenses and demands which could be incurred or incurred in relation to any losses, damages or injuries which could arise from the participation of the beneficiary of the P.R.O. Kids Edmundston program before, during and after participating in the activity of their choice.

The applicant releases the municipality of Edmundston, the Edmundston Recreation and Sports Department, P.R.O. Kids Edmundston their agents, mandataries and employees towards the smooth running and quality of the activity selected by the beneficiary from all liability.

The personal information that appears on this form will be kept confidential and may only be reproduced with the consent of the applicant. It will be used to keep a register of people who use the P.R.O. Kids Edmundston services.

Please direct your questions to our coordinator at the Sports Pavilion, P.O. Box 605, Edmundston, NB, E3V 0G4 or by calling (506) 737-6925.
I have read and I understand the declaration above / J'ai lu et je comprends la déclaration ci-haut
Signature*
Date*

MonthDayYear
Date
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