THRIVE Registration Form

Thrive Registration
About THRIVE

The THRIVE Family Development Project is a FREE, 3-week, Monday to Friday program that supports families with young children by removing barriers and creating opportunities. While parents and caregivers take part in individualized workforce training and employment support, their pre-school children receive quality care and early childhood development activities with Registered Early Childhood Educators.

Currently, THRIVE is offered at Port Cares in Port Colborne and The Hope Centre in Welland, providing families with a safe, welcoming space to strengthen financial stability and prepare children for a positive transition into school.

Upcoming Groups (can be selected on next page):
- The Hope Center in Welland - November 10 - November 28
- Port Cares in Port Colborne - December 1 - December 19
- The Hope Center in Welland - January 5 - January 23
- Port Cares in Port Colborne - January 26 - February 13
- The Hope Center in Welland - February 23 - March 13
- Port Cares in Port Colborne - March 16 - April 2
Participant Information
Participant Name*

First NameLast Name
Participant Birth Date*

MonthDayYear
Participant Phone Number*
Please enter a valid phone number.
Participant Email
example@example.com
Participant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Children Information
Will you be needing childcare during the Thrive program?

YesNo
How many children would need childcare?

1234
Child 1 - Name

First NameLast Name
Child 1 - Date of Birth

MonthDayYear
Date
Child 2 - Name

First NameLast Name
Child 2 - Date of Birth

MonthDayYear
Date
Child 3 - Name

First NameLast Name
Child 3 - Date of Birth

MonthDayYear
Date
Child 4 - Name

First NameLast Name
Child 4 - Date of Birth

MonthDayYear
Date
Does any of your children have any allergies, medical conditions, chronic illnesses or special considerations? Please specify below.
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number

CONSENT TO COLLECT, RELEASE, USE, STORE AND DISCLOSE INFORMATION
I,*

Participant First NameParticipant Last Name
Of address:*
e.g. 123 Street Road, Port Colborne ON
In accordance with The Federal Personal Information Protection and Electronic Documents Act (PIPEDA); The Personal Health Information Protection Act (PHIPA) of Ontario; Ontario's Freedom of Information and Protection of Privacy Act (FIPPA) and the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA)

Hereby consent to the collection, use, storage and disclosure of my personal information with:

Port Cares

PCWorks

EarlyON Child and Family Centre
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Thrive Registration

Participant Information

Almost done! - let us get to know you!

CONSENT TO COLLECT, RELEASE, USE, STORE AND DISCLOSE INFORMATION