Girls Who LEAP Program Registration Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Phone*

Area CodePhone Number

Email*

example@example.com

Birthday*

MM/DD/YYYY

Grade*

School*

Parent/Guardian*

First NameLast Name

Parent/Guardian Primary Phone*

Area CodePhone Number

Parent/Guardian Secondary Phone

Area CodePhone Number

Parent/Guardian Email*

example@example.com

Emergency Contact*

First NameLast Name

Emergency Contact Phone*

Area CodePhone Number

Relationship to Youth*

Doctor's Name

Doctor's Phone Number

B.C. Care Card Personal Health Number*

Does your child have any dietary restrictions or preferences? If yes, please describe and list all food allergies:*

Example: allergic to peanuts, vegetarian, vegan, gluten-free

Will your child be bringing medication to any of our events including an EPI pen?*

YesNo

Is your child subject to any of the following? Check all that apply.*

If you indicate yes to the above question, please provide additional information.

Any other medical or health concerns we need to know:*

Is your child is allowed to be administered these medication with your permission? Check all that apply.*

NOTICE TO PARENT/GUARDIAN: It is a condition to the child's participation in the program that you, the undersigned Parent/Guardian of the child, must carefully read and understand this document and sign it to acknowledge that you have read and understand it and that you understand that the child's participation in the program will expose the child to risks of harm and that you accept full responsibility for exposing the child to such risks.

EMERGENCY MEDICAL CONSENT: I confirm that the above information is correct and I hereby give consent and full authority for the staff, volunteers and mentors of Girls Who LEAP and its affliate partner organizations, to administer first aid to the child and/or arrange for and consent to any medical treatment or hospitalization for my child/ward while he/she is in the care of the program. I further authorize these members to enter into and execute, on my behalf, such documents or consents as may be required by Medical Practitioners, Health Care Professionals or Hospitals for such purposes. I understand that it is my responsibility to inform the staff of Girls Who LEAP and its affliate partner organizations, of any new medical condition or change to the information provided as early as possible.

PARENT/GUARDIAN RESPONSIBILITY FOR CHILD: I, the undersigned Parent/Guardian of the Child, understand and accept that, with respect to the Child's participation in the program, it is my responsibility (1) to ensure that I consider and understand the risks, dangers, hazards and consequences of injury inherent in the program, (2) to determine, taking into consideration those risks and the Child's behavioural characteristics, physical health and abilities, whether the Child should be allowed to participate in the program, (3) to ensure that the Child is appropriately covered by medical insurance for any harm occurring in the program, and (4) to provide emergency medical information regarding the Child as required in this document.

AWARE OF RISKS: I AM AWARE OF, AND NOW FREELY ACCEPT AND ASSUME RESPONSIBILITY FOR, ALL RISKS TO THE CHILD IN CONNECTION WITH THEIR PARTICIPATION IN THE PROGRAM, INCLUDING AS FOLLOWS:
(1) the Child's participation in the program, even if the Child possesses behavioural characteristics, physical health and abilities appropriate for the program, poses risks of harm to the Child;
(2) the nature of the program is such that the Girls Who LEAP cannot identify all risks associated with the program and cannot guarantee that staff and mentors participating in the program will not make errors therein or that other children participating in the activities will not cause injuries therein others that staff can or might be able to prevent.

I, THE UNDERSIGNED PARENT/GUARDIAN, AM THE PARENT AND/OR LEGAL GUARDIAN OF THE CHILD AND I HEREBY CONSENT TO THEIR PARTICIPATION IN THE PROGRAM, AND, IN RETURN FOR GIRLS WHO LEAP ALLOWING THE CHILD TO PARTICIPATE IN THE program:
1) I NOW WAIVE ALL LEGAL RIGHTS TO SUE AND ANY AND ALL CLAIMS which I and/or my successors and assigns may have against Girls Who LEAP, its directors, officers, volunteers, mentors, staff, affliated partners and funders in connection with any loss, injury, damage or expense that I may suffer, incur or experience in connection with the Child's participation in the program; and
2) I HEREBY RELEASE Girls Who LEAP, its directors, officers, volunteers, mentors, staff, affliated partners and funders from any and all liability for any complaints, demands, claims, actions, suits, judgements and orders for, or with respect to, any and all losses, injuries, damage or expenses I may suffer, incur, or experience in connection with the Child's participation in the program; and
3) I AGREE TO INDEMNIFY Girls Who LEAP, its directors, officers, volunteers, mentors, staff, affliated partners and funders for, and hold it harmless from, any and all losses, injuries, damages and expenses of any kind that the program may suffer, incur or experience and for any and all complaints, demands, claims, actions, suits, judgements and orders against it with respect to any and all loses, injuries, damages or expenses of any kind anyone else may suffer, incur or experience to the extent they or any of them may arise from, or in connection with my conduct or the Child's conduct in, or with respect to their particiation in the program.

PICK-UP PERMISSION : I understand that it is my responsibility to pick-up or to make suitable arrangements for the pick-up of the Child, immediately on completion of the program, and to communicate clearly and effectively to Girls Who LEAP mentors, prior to commencement of the program, any special instructions regarding the pick-up of the Child on completion of the program.

TRANSPORTATION CONSENT: I give permission for the Child to be transported to/from programs via various forms of transportations including, but not limited to, public transit, buses, personal vehicles, ferries, chartered planes, boats.

PERMISSION TO UTILIZE PHOTOS AND TESTIMONIALS: Permission is given to Girls Who LEAP and its affliate partner organizations to use testimonials, photographs (individual or group) and/or multimedia images and recordings in the best interest of the program without compensation to the child or anyone else. In signing this document and permitting the Child to participate in any and all Girls Who LEAP programming, I do not rely upon any oral or written statements, promises or other communications made by the program other than that set out in this document.

Note: All references herein to the Girls Who LEAP include affliated partners and funding organizations including but not limited to Face of Today Foundation, The Landing Youth Centre, The Vancouver Basketball Foundation, School Boards, Community Centres, the City of Vancouver and its Board of Parks and Recreation, any society or association involved in the operation of and/or provision of programs or services, on and off site locations and all of their respective officials, directors, officers, employees, volunteers and agents. Anyone under 19 years of age - infant, child or youth - is defined as child in legal terms. I have read and understand this document.

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Signature (alumni 19+ can sign their own registration)*

Program Registration

Registrant Information

Parent/Guardian Information

Child Medical Information

Parent/Guardian Authorization