2026 Full Program Consent Form

Program Consent Form - 2026
I,parent/guardian name give permission for my child/youthyouth nameto participate in programs facilitated by Kneehill Regional Family and Community Support Services (KRFCSS).
General Information: The information provided in this consent form will be used for all programs your child/youth is registered for from the date this form is signed until December 31ˢᵗ, 2026.

IMPORTANT - Participants must be registered to each program they want to participate in as spaces are limited.

Confidentiality Information: KRFCSS programs are based on a trusting relationship. The facilitator(s) will keep information shared by participants confidential except in situations where there is an ethical obligation to break confidentiality such as if your child/youth reveals information about harming themselves or others, child abuse, or criminal activity. For liability purposes, some facilities may require KRFCSS to provide a list of participant names so they know who is accessing their building. If you are not comfortable with your child's name being shared, or if you have any questions, please contact Raelene directly at Raelene.lupul@krfcss.com or 403-443-3800. If you are not comfortable filling out a Program Consent form online through Jotform, please print the pdf and email the completed form to Raelene.lupul@krfcss.com.

Outside Activity: If weather permits, some program activities may take place outside within the town/village the program is located. Participants will always be accompanied by KRFCSS facilitators (Examples include the local field, playground, or a nature walk. Please be sure to provide your child/youth with weather appropriate clothing and footwear, sunscreen, and bug spray as these items are NOT provided by KRFCSS.
Participant Information:
Full Name:
Date of Birth:

MonthDayYear
Date
School:
Grade:
Health/Allergy Concerns:
Any additional considerations:
Parent/Guardian Information:
Parent/Guardian Names:
Phone #:
Parent/Guardian Email:
example@example.com
Would you like to be added to our emailing list for future events?
Emergency Contact Information:

(If you cannot be reached)
Name:
Phone #:
Pick-up Authorization:

Please indicate your pick-up preferences below. If you have any concerns, please contact raelene.lupul@krfcss.com
Pick-up Authorization:

Self Checkout - I authorize that my child/youth may check themselves out. I understand that my child/youth will meet their pick-up person at the vehicle, will walk home, or go to another activity after the program session.Signed Pick Up – My child/youth MUST be signed out by a parent, guardian, emergency contact, or an additional person listed when registering in a program. Facilitators are not permitted to release your child/youth to anyone not listed when registering or on this form.
Media Release Consent

Kneehill Regional FCSS uses photos in publications, promotional material, and presentations such as annual reports, brochures, advertisements, promotional displays, or newspapers. We appreciate your permission to use these images in the manner outlined above.
Media Consent:

YES, I authorize Kneehill Regional FCSS to produce, use, exhibit, display and distribute the PHOTOGRAPHED IMAGES of my child/youth in connection with the promoting, publicizing, or explaining programs facilitated by KRFCSS.NO, I do not authorize Kneehill Regional FCSS to produce, use, exhibit, display and distribute the PHOTOGRAPHED IMAGES of my child/youth in connection with the promoting, publicizing, or explaining programs facilitated by KRFCSS.
Please sign below to acknowledge that you have read, understood, and agree to the terms in this consent form and verify that the information provided is true and correct.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Please click the submit button to complete your consent form.

If you would prefer to fill out a paper copy, please fill out, print, scan and email to Raelene.lupul@krfcss.com or drop off the form at the KRFCSS office at 779 2 Street NE, Three Hills. if you have any questions or barriers to submitting your consent form, please email Raelene.lupul@krfcss.com or call 403-443-3800.
Should be Empty:

Program Consent Form - 2026

Participant Information:

Parent/Guardian Information:

Emergency Contact Information:

Pick-up Authorization:

Media Release Consent