Welcome to the Hillside Community!
Please complete these forms and include any children or caregivers who may be participating in Hillside activities. These forms allow us to develop safe and inclusive programs with meaningful opportunities for all participants.
Family Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Does anyone in your family have any allergies, food restrictions, or medical conditions?
*
no
yes
If you answered "yes" to an allergy/sensitivity, please describe the allergen, reaction, and required treatment. For a medical condition, please provide a diagnosis such as "asthma" or "epilepsy". Include the individual's first name.
No.1 Child's Name
*
First Name
Last Name
No.1 Child's Birthdate
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Additional Children
For 2 or more children, see additional spaces on page 3.
Additional Parent/Caregiver if applicable
First Name
Last Name
Additional Parent/Caregiver Phone Number
Format: (000) 000-0000.
If any of the following are a concern or challenge for a person in your family, and you would like to discuss needs or supports for participation, please let us know! We would be happy to chat with you!
sight/vision dysfunction/reading
hearing/communication/speech+language
mobility/physical ability
sensory processing differences
anxiety/mental health
developmental disability
behaviour/safety
Please let us know how we can support your family in participating and experiencing a sense of belonging at Hillside. Your feedback is valuable. We plan our programming and adapt our activities to engage every participant in meaningful connection and opportunities.
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Photographs are a valuable way of documenting children's play and learning. These images are often appreciated and enjoyed by children and their parents. If you give permission to have pictures/videos of you and your child/children taken during Hillside House activities, please indicate your preference. You can also choose not to give permission for any photos.
*
I would like photographs of my child/family taken during Hillside House activities. Please share these images with me by email.
I would like photos and videos of my child/family taken during Hillside House activities. Please send these to me via Facebook Messenger. I will provide a Facebook Messenger account to the program coordinator.
I DO NOT give Hillside House permission to take any photos of my child/family.
We use authorized photos to create social media posts and advertisement. We want our marketing to be an honest reflection of who we are and what we do. For this reason, we prioritize using photos taken during activities over using stock photos. Your permission to use photos allows us to create marketing materials that represent all participants and not only a few. Hillside is a safe, caring and inclusive community. Our social media posts and our advertisement are created to support our values. Let us know if you would like to be featured in our advertisement and social media posts!
I give Hillside House permission to take photos my child/family participating in Hillside House programming. These images may show my face / my child's face and may be used for future marketing materials. This may include but is not limited to: Facebook, newspaper articles, brochures. and Hillside House website.
I give Hillside House permission to take photos my child/family participating in Hillside House programming. These images will not include faces from the front or side, but can be taken from behind or above during activities. These images may be used for future marketing materials. This may include but is not limited to: Facebook, newspaper articles, brochures. and Hillside House website.
Informed Consent: At Hillside House we support children in becoming confident, capable people who have a sound sense of their abilities and interests. We will offer opportunities for both unstructured free play as well as open ended structured activities. Outdoor play and learning are central to our program. We support children’s developing ability to take age-appropriate responsibility for their own safety. Unstructured play allows children to explore, problem solve, fully engage and connect with their environment and the natural world. We take reasonable steps to manage and balance risks, while at the same time allowing children to play freely. Program participants acknowledge its inherent risks of harm and personal injury. While minor injuries like bruises, bumps and scrapes are not uncommon, serious injuries are rare, and life-changing injuries and fatalities are unlikely in the extreme. Still, as with any activity, indoors or outdoors, it is impossible to guarantee that they will not happen. During drop-off programs, the facilitator will be responsible for children’s safety. During family activities, parents or guardians will be responsible for supervising and supporting their children during outdoor activities. You are required to accept this as a condition of your child’s participation. Risks: The variety of risks in outdoor play is more than can be listed here and will vary depending on the program or activities. Here is a list of some of the more significant risks...*Injuries from executing strenuous and demanding physical activities.*Injuries resulting from matches or fire (scheduled campfires and fire building)*Injuries resulting from the presence of harmful plants, natural loose parts, wild or domestic animals, insects or ticks *Changing and inclement weather including storms, high winds and lightning *The possibility that your child may not heed safety instructions or directions given to the group or delivered individually *Injuries arising from the actions of other children *Negligence on the part of other participants. All rules are designed to enhance the safety of your child and others and are to be followed at all times. While the injuries sustained in outdoor activity are mostly minor, they can be severe, and on extremely rare occasions, even fatal. Fire and open-fire cooking require special instructions and training from the facilitator. Children must be accompanied by a guardian or educator at all times around a fire. Your child’s risk of injury increases with fatigue. In unstructured, outdoor play, children freely choose which experiences and forms of play they are comfortable engaging in. You and your child are under no obligation to participate in all experiences and you may choose not to participate in an activity at any time during the program.
*
I have read and understand this Informed Consent Form.
Hillside House has a safety binder with risk-benefit assessments for many of our activities/experiences. These documents are available to staff and parents to read.
*
I am aware that I can request and read the risk-benefit assessment summaries for Hillside activities/experiences.
Children should be supported by caregivers in making age-appropriate choices for risky play within safe boundaries and with clear expectations.
*
I/We have explained to our child that they need to listen to and follow the instructions provided.
I/We are aware that alongside the benefits, participation involves risks, dangers, and hazards, including but not limited to those referred to in the "informed consent form" and I/We Freely and voluntarily assume the risks, dangers, and hazards inherent in participating, including all those described in the risk-benefit assessment summaries and the possibility of personal injury, and the remote possibility of fatality.
*
Being satisfied that participation is suitable for my/our child, I/we give my/our permission and consent for him/her/them to participate.
I understand that I need to inform the program coordinator or the activity facilitator if I or my child has a medical or health condition that will impact our participation. Hillside House facilitators will prioritize safety during activities.
*
I will notify you if I or my child suffers from any medical or health condition that may cause injury to themselves or others, or may require emergency care during their participation or if their medical or health condition changes.
Parent/Guardian's Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact
First Name
Last Name
Emergency Contact
Please enter a valid phone number.
Format: (000) 000-0000.
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No.2 Child's Name
First Name
Last Name
No.2 Child's Birthdate
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
No.3 Child's Name
First Name
Last Name
No.3 Child's Birthdate
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
No.4 Child's Name
First Name
Last Name
No.4 Child's Birthdate
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
No.5 Child's Name
First Name
Last Name
No.5 Child's Birthdate
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
No.6 Child's Name
First Name
Last Name
No.6 Child's Birthdate
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
No.7 Child's Name
First Name
Last Name
No.7 Child's Birthdate
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
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