KidZinc Registration Form

Child(ren)s Primary Address*

Street Address

CityPostal Code

Postal Code
Home Language (if other than English)
Do you have a custody order?*

YesNo
Do you have a protection order?*

YesNo
If answering "yes" to either of the above questions, a copy of the order must be provided to KidZinc prior to your child's start.

Parent/Guardian One
Name*

First NameLast Name
Relationship to child*
Address*

Street Address

Street Address Line 2

CityPostal Code

Postal Code
Workplace Name*
Workplace Address*
Cell Phone Number*
Home Phone Number
Work Phone Number
Email Address*
By providing your email, you authorize KidZinc to send periodic emails directly related to your child's care.
Parent/Guardian Two
Name

First NameLast Name
Relationship to child
Address

Street Address

Street Address Line 2

CityPostal Code
Workplace Name
Workplace Address
Cell Phone Number
Home Phone Number
Work Phone Number
Email Address
By providing your email, you authorize KidZinc to send periodic emails directly related to your child's care.

Emergency Contacts
Must be a person other than a parent/guardian who lives in Calgary or surrounding area. This person is authorized to pick the child up from the program in emergency situations only and only when a parent/guardian cannot be reached.
Emergency Contact 1

Required, cannot be parent/guardian
Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityPostal Code

Postal Code
Relationship to child*
Optional: This person is also authorized as an alternate pickup and can pick up my child(ren):

At anytimeOnly with notification
Emergency Contact 2

Optional
Name

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

CityPostal Code

Postal Code
Relationship to child
Optional: This person is also authorized as an alternate pickup and can pick up my child(ren):

At anytimeOnly with notification

Authorized Alternate Pickup Contacts
Anyone other than parent/guardians who are permitted to pick-up the child(ren) from the program. Must be over the age of 16, unless they are a sibling of the registered child, and are required to provide photo ID at pickup.
Name

First NameLast Name
Phone Number
Relationship to child
This person can pick up my child(ren):

At anytimeOnly with notification
Name

First NameLast Name
Phone Number
Relationship to child
This person can pick up my child(ren):

At anytimeOnly with notification
Name

First NameLast Name
Phone Number
Relationship to child
This person can pick up my child(ren):

At anytimeOnly with notification

Media Release
Check all that apply

I give consent for my child’s artwork or writing to be used in KidZinc newsletters, posters, brochures or other written marketing materials.I give consent for my child’s artwork or writing to be used on the KidZinc website.I give consent for my child’s artwork or writing to be used on KidZinc social media accounts (Facebook, Instagram, Twitter)I give consent for my child’s photo to be posted in their specific KidZinc program (i.e. Birthday wall or award recognition).I give consent for my child’s photo/video to be used in KidZinc newsletters, posters, brochures or other written marketing materials.I give consent for my child’s photo/video to be used on the KidZinc website.I give consent for my child’s photo/video to be used on KidZinc social media accounts (Facebook, Instagram, Twitter)
OR

I do not give any media release consent for my child.
I provide KidZinc with media release consent under the conditions noted above.*

Agree
Signed:*
A typed name is accepted as a legal electronic signature

Parent Volunteer Commitment

KidZinc recognizes the importance of family involvement in the success of its programs. Parents/guardians will be presented with a variety of volunteer opportunities and are encouraged to volunteer at least once per school year.
Please indicate below which volunteer areas are of interest to you.

Casino Fundraiser.Participate in community projects to help raise the profile of KidZinc (community clean up, skating rink maintenance, community gardens).Participate directly in the program for special events.Board of Directors/Board Committee (Locations, Fund Development, Strategic Planning).Present a workshop to children in the program based on personal skill set. (ie. karate instruction, art instruction, sports instruction)Provide instruction and support to organization based on personal skill set. (ie. IT support, marketing support, legal advice)
Area(s) of expertise:

Authorization
Each of the following are required to submit this form*

I understand that each check box/typed name within this document constitutes electronic consent in lieu of an original signature on paper.I confirm that, to the best of my knowledge, all information contained in this document is accurate.I agree to all terms and conditions of service as outlined in the KidZinc Family Handbook.
I agree to the above terms.*

Agree
Signed:*
A typed name is accepted as a legal electronic signature
Should be Empty:

Child One