Clone of Youth Campus Tours October 2025

Youth's Name

First NameLast Name

Youth's Email

example@example.com

Birth Date

MonthDayYear

Age

Gender

What is your First Nation?

Ontario Health Card #

Residential Address (Currently Living)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What grade are you currently in?

What are your top three colleges or universities, ranked from your first choice to your third choice?

What program are you looking to take in post-secondary school?

Please write a brief description on why you would make a suitable candidate for this tour.

Parent/Guardian Information

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Alternate Number

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Does the youth have any allergies, chronic illness, or medical conditions? If yes, please describe.

Does the Youth have any dietary needs? If yes, please describe.

I acknowledge that by allowing my child to participate in the trip/events organized by the Mushkegowuk Council Youth Department, I understand and accept that photographs and video recordings may be taken of my child and other participants throughout the duration of the trip. I hereby give consent to the Mushkegowuk Council Youth Department to capture and share such images or recordings on official Mushkegowuk Council social media platforms.I understand that the intended use of these images and recordings is solely for promotional and public awareness purposes related to the organization. By signing this release, I waive any claim to privacy or compensation regarding the use of my child’s image or recordings on social media as described above.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Mushkegowuk Council Youth Department during the events/activities/trips. I understand there is a risk of being injured that is inherent in all sports activities. The risks and hazards incidental to the conduct of the activities, and release, I absolve and hold harmless Mushkegowuk Council Youth Department and all its respective staff, chaperones, and representatives. Any and all liability for injuries to said child arising out of traveling to, participating in, or returning from events/activities/trips.

Furthermore, I grant consent to the Mushkegowuk Council Youth Department to review, complete, and sign any required waivers on behalf of my child for recreational or program-related activities during the trip, should it be necessary. This authorization ensures my child’s full participation in planned activities while maintaining the Department’s commitment to their well-being and safety.

Medical Release and Authorization

As Parent and/or Guardian of the named youth, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named youth. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible.

Permission is also granted to the Mushkegowuk Council Youth Department and its affiliates including Trainers, Coaches, and Chaperones to provide the needed emergency first aid treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the Youth Campus Tour Trip October 18th-25th.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Parent/Guardian Signature

Mushkegowuk Youth Department

Youth Information

Media Consent