Youth Programs Information Form

The purpose of the Youth Programs Information Form is to provide contact and emergency information for your child while participating in the Shilo MFRC Youth Programs.

For any questions/concerns regarding this program, please contact:
Shannon Chapman, Youth Programs Coordinator
shannon.chapman@forces.gc.ca
204-765-3000 ext. 4558

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1. Youth's Information:

Name:

Grade:

Date of Birth:

Physical Address:

Home Phone number:

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2. Parent/guardian's Information:

Name(s): *

Primary Phone Number: *

Alternate Phone Number: *

Email address: *

Physical address (if different from above)

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3. Other Parent/guardian's Information:

Name(s):

Primary Phone Number:

Alternate Phone Number:

Email address:

Physical address (if different from above)

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4. Emergency Contact: (someone other than those listed above, in case they can't be reached)

Name:

Primary Phone Number:

Alternate Phone Number:

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5. Does your child have any allergies or specific medical or behavioural conditions the MFRC Staff should be aware of?

Yes

Please give details including the symptoms, severity of conditions, if your child carries an EpiPen or inhaler, and any other details that would be of assistance:

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6. Do you grant permission to the Shilo MFRC youth programs, to take your child on local outings, such as walks in the wooded area surrounding the base, walks to bunker hill, Canex, GSH outdoor facilities, and the residential areas.

Yes

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7. Do you grant permission to the Shilo MFRC, its agents, and employees, the right to photograph you and/or your minor child registered for this program for use in any MFRC publication including print, web sites or other electronic form of social media.

Yes

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8. If your child is in grades Kindergarten-6, please indicate how your child will be getting home at the end of the program.

Walking or biking themselves home

Picked up, do NOT let walk home

**Youth in grades 7-12 will be allowed to come and go from the centre at their own discretion. Children in Grades K-6 will be required to stay for the duration of the program unless other advised by the parent.

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9. Acknowledgment and Consent:
1. I acknowledge that it is my responsibility to advise the Youth Programs staff member of any medical or behavioural concerns of my child that may affect his/her participation in Youth Centre activities.
2. I understand that the Shilo MFRC is responsible for my child only during the time he/she is inside the Youth Centre.
3. I acknowledge that the staff of the Shilo MFRC will secure medical advice/services and will report any concerns as deemed necessary for the health and safety of anyone participating in Shilo MFRC programs. The Shilo MFRC does not assume financial responsibility for any cost associated with seeking medical advice.
4. I acknowledge that my child is accountable to Youth Centre Rules. If my child does not abide by the rules, they may be subject to the Youth Centre behaviour management policy.
5. I acknowledge that it is my responsibility to update the Shilo MFRC Youth Programs Coordinator, of any changes to vital information.

I agree with the above statements.

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10. FOR OFFICE USE ONLY - DO NOT COMPLETE

Date:

Amount Paid:

Receipt #:

Staff Initials: