Circle Drop In Registration Fall 2024

The purpose of this form is to inform you about the Circles Drop-In Program and to seek your support and permission for your child to participate. This information may be shared as necessary with the Youth Unlimited (Toronto Youth for Christ) staff/volunteer supervising the program. All Youth Unlimited (YU) programs are led by YU leaders who are either staff or volunteers and who have been YU safety-checked and are organized according to YU policy for the safety of each participant. Please feel free to contact the leader(s) if you have any questions or concerns.

A form signed by you is required before your child can begin participation. This is an important document. If needed, please ensure that someone translates and explains this document to you.

(The below information will be sent to your email after you submit the form)

Name of Program: Circles Drop-In Program

Telephone: (416) 383-1477 ext. 7224

YU Leader: Matt Escott and Bianca Armstrong

Program Location: Blythwood Road Baptist Church, 80 Blythwood Rd, Toronto

Program Start Date: November 6, 2024

Program End Date: December 11, 2024

Program Times: Every Wednesday from 4-6pm

Requirements for Participants

Food/snacks: We will provide a light snack upon arrival at 4:00pm, as well as a dinner that will be served around 5:30pm.

Money: There is no cost to you for this program.

Clothing and Equipment: Clothing that is comfortable to move around in.

Other:

As part of the program, your child may be participating in the following activities which may involve risk or special safety considerations. (Supervision by a YU leader will be provided): Gym sports (Basketball, Volleyball, etc.)

Program Leader

Onsite YU leader: Matt Escott and Bianca Armstrong

YU contact during the activity: Matt Escott or Bianca Armstrong

Phone: (416) 383-1477 ext. 7224

YU Leader Signature: Matt Escott, Bianca Armstrong

Date: October 3, 2024

This is a legal document. The collection and retention of the information requested on this form is authorized and governed by the Freedom of Information and Protection of Privacy Act (Ontario) and the Personal Information Protection and Electronic Documents Act (Canada).

Name of child/youth

First NameLast Name

Gender

Other

YES, I/we give permission for my/our child, First Name Last Name to participate in the Circles Drop In program from November 6, 2024 through December 11, 2024, and to receive electronic communications from program leaders.

Emergency Contact Name

First NameLast Name

Relationship to the child/youth:

Emergency Contact phone number

Format: (000) 000-0000.

Health Card No. [optional]

Allergies/Health/Diet Issues: (Please also describe any relevant recommendations for how we should respond)

Is there any medical reason why your child should not participate in an activity, or which may lead him/her to require special attention during the activity? (If yes, please specify what activity and what special attention they require)

Medications required: (Please also include Times and Instructions)

Should it become necessary for my/our child to receive medical care, I/we hereby give the YU leader permission to use her/his best judgment in obtaining such care for my/our child, including transporting my/our child in the case of an emergency. I/we understand that any cost will be my/our responsibility and I/we agree to indemnify any such costs YU incurs on my behalf. I/we also understand that in the event of illness or accident, the emergency contact person will be notified as soon as possible.

I/we understand that my/our child’s participation in this activity may have undesired and unanticipated consequences. Notwithstanding this, I/we hereby release and forever discharge Youth Unlimited (Toronto Youth for Christ) and all affiliates, members, directors, officers, leaders, agents, volunteers and employees from any and all actions, causes of action, suits, claims, demands, liabilities, including negligence, and all expenses I/we have now or may have in future in connection with, arising from or related to my/our child’s involvement with or participation in this activity and agree to indemnify YU for any and all legal and other costs associated with defending any such claim.

What are some of your child's interests and hobbies? What do they love to do?

Tell us about some of your child's strengths. What are they great at? What are they proud of? What do you admire about them?

Please let us know about any concerns you have regarding your child's behaviour and/or emotional regulation, as well as any coping/calming strategies that you have found to be helpful. We ask this so that we can be well-equipped to support your child, in order to provide the best possible experience for them at the Circles Drop-In Program.

If you would prefer to discuss any concerns by phone, please indicate below what days and times are best for us to reach you.

I give permission for my child to be dismissed from the Circles Drop-In Program unattended.

If you have not given permission for your child to be dismissed from program unattended, who else do you authorize to pick up your child (limit of 3 names).

PARENT/GUARDIAN INFORMATION & SIGNATURE - (needed if a child/youth is under 18 and dependent on a parent/guardian)

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Signature of Parent/Guardian

Your signature - please use your mouse or finger to sign!

Parent/Guardian Release of Liability

Health Information

About My Child