PERSONAL INFORMATION PROTECTION ACT (PIPA)

PERSONAL INFORMATION PROTECTION ACT (PIPA)
Name

PARTICIPANT’S FIRST NAMEPARTICIPANT’S LAST NAME
PARTICIPANT’S DATE of BIRTH

MonthDayYear
Date
GENDER
Address

ADDRESS

Street Address Line 2

CITYState / Province

POSTAL CODE
Name

PARENT/GUARDIAN FIRST NAMEPARENT/GUARDIAN LAST NAME
EMAIL
example@example.com
GYMNASTICS CLUB NAME
GYMNASTICS CLUB NAME
Your personal information such as Name, Date of Birth, Gender, Address, Phone, and Email will be protected and managed in accordance with the PIPA and made available only to the staff of the Gymnastics Club and Alberta Gymnastics Federation (pertaining to any information related to Alberta Gymnastics Federation Membership, this includes but not limited to emails for special events, live broadcasting, video, results, website, noticeboards, advertising, photos, social media platforms, funding, and Team Alberta requirements). Non- identifying information will be provided to GymCan and the Sport, Physical Activity and Recreation stakeholder services
Personal Information/Photo/Video Release

YESI give consentNO,I refuse consent
Personal Information/Photo/Video Release

YESI give consentNO, I refuseconsent
Personal Information/Photo/Video Release

YES,I give consentNO,I refuseconsent
To send information(Pertaining to Alberta Gymnastics Federation Membershipand the GymnasticsClub

programs. This includes but not limited to emails, newsletters, special events, general information,

fundraising, donation request, invoices, honorariums, Team Alberta, etc)

To take pictures or video of me/my child during my/their participation in any program, and that these

may be used for advertising, newsletters, noticeboards, website, live broadcast, special events, Team

Alberta, and any social media platform(Gymnastics Club and Alberta Gymnastics Federation)

To take pictures or video of me/my child during my/their participation in any program, and that these

may be used for training purposes.
Note should you chose you can withdraw your consent in written notice at any time to*
If you need any additional information about our personal information protection act, you can contact Alberta Gymnastics Federation office at (403) 259.5500 or via email at info@abgym.ab.ca.
day of
day of
, 20
at
Signature of Participant (if over 18 years of age)

Signature of Parent or Guardian (as named above)
Should be Empty: