Speakers Club

Speakers Club

Regristration
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Ethnicity/ Cultural Background *
Provincial Health Number (PHN)*
Allergies/Medical Conditions*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email*
example@example.com
Preferred Method of Contact

CallTextEmail
Parent/Guardian Information
Name*

First NameLast Name
Relationship to Applicant*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact
Name*

First NameLast Name
Relationship *
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Additional Information
How did you hear about the program?*

Friend/FamilySchoolSocial MediaOther
Do you have any special requirements or accommodations needed?
Any additional comments or information you would like to share?
Consent Agreement
Parent/Guardian Consent:
I, the undersigned, give permission for my child to participate in the Volunteer Terrace and Skeena Diverity program and agree to the policies and guidelines set forth by the program coordinators.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Media Release

I grant Volunteer Terrace and Skeena Diversity, its representatives, volunteers, and employees the right to take photographs/videos of me and my property in connection with the above-identified subject. I authorize Volunteer Terrace and Skeena Diversity to assign its and transferees to copyright, use and publish the same in print and/or electronically. I agree that Volunteer Terrace and Skeena Diversity may use such photographs/videos of me with or without my name and for any lawful purpose, including examples such as for purposes of publicity, illustration, advertising, social media, and web content.
Date

MonthDayYear
Date
Should be Empty:

Speakers Club

Personal Information

Parent/Guardian Information

Emergency Contact

Additional Information

Consent Agreement

Media Release