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PARTICIPANT INFORMATION SHEET

PLEASE FILL OUT ALL SECTIONS

PLEASE SELECT YOUR AGE GROUP
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WHICH CENTRES WILL YOU BE ATTENDING?
For multiple selection, please hold the CTRL key and click the option.
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PLEASE NOTE: YAC Membership does not guarantee access.
Space is granted daily on a first come, first served basis. Attendance capacities will be enforced. 
Child’s Legal Name:
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First Name
 
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Last Name
Name commonly known as:
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Male/Female/Other Please Specify
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Age
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BIRTHDATE
Languages known/spoken:
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Email:
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Would you like Parks & Recreation Services to update you on future youth programs and opportunities?
 
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Parent/Guardian Parent/Guardian
Name:
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Address:
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Home Phone:
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Cell Phone:
Work Phone:
Relationship:
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Name:
 
Address:
 
Home Phone:
Cell Phone:
Work Phone:
Relationship:
Phone number valid format: 204 123 4567, (204) 123 4567, 204-123-4567, (204)-123-4567, 2041234567, (204)1234567
Designated Emergency Contacts – MUST BE COMPLETED IN FULL
Designate 2 people other than listed above that we can contact and release information to in case of illness or emergency.
Name:
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Home Phone:
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Cell Phone:
Work Phone:
Relationship:
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Name:
 
Home Phone:
Cell Phone:
Work Phone:
Relationship:
Medical / Personal Information
Describe any medical conditions or allergies of which we should be aware:
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Describe any cultural, religious or personal requirements or restrictions of which we should be aware:
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General Illness
By initialling below, I acknowledge that if my child shows any signs of illness including coughing/sneezing, sore throat, nausea, upset stomach, diarrhea, vomiting, shortness of breath or fever prior to arrival, I will not send my child to YAC until such time as those symptoms have subsided for at least 24 hours. In addition, if during the course of the day my child becomes ill with any of the symptoms listed above, I agree to arrange to pick my child up from camp within 20 minutes of being informed by the Recreation Leaders.
Parent/Guardian Initial:
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Emergency Medical Transportation and Treatment
If, at any time, medical treatment is necessary due to serious injury or sudden illness, by signing below I authorize the City of Brandon, its staff or agents to take whatever emergency measure deemed necessary for my child’s protection. I understand that any expense incurred for medical treatment, including ambulance fees, are my responsibility.
Parent/Guardian Parent/Guardian
Signature:
Click Here To Sign*
Print Name:
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Date:
 
Signature:
Click Here To Sign  
Print Name:
 
Date:
 
Consent to Photograph or Videotape
On occasion throughout the duration of this program, photographs or videos may be taken for the purpose of media or advertising of the program. By signing below, it is acknowledged that pictures of the parent/guardian and/or child may be used for this purpose.
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Parent/Guardian Initial:
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Public Transportation Waiver
On occasion, throughout the duration of this program, youth may participate in activities that occur away from the main location of the program. In order for youth to participate in these activities, a signature by the youth’s parent/guardian is required. Youth whose forms are not signed will not be able to attend such events. It is possible the program centre may not be open when the program is taking place off site. In such cases, the child will not be able to attend the centre. Events taking place off of centre grounds will be identified on the activities calendar and posted at the centre. Youth will also be reminded about these activities by their leaders in advance. If youth need to leave early, alternate transportation must be arranged by their parent/guardian. By signing below, it is acknowledged and approved that the child will be participating in activities in various locations away from the program centre, and consent is given for the child to utilize public transportation to such activities and events. It is also recognized that these events are subject to change or cancellation, and such changes will be posted at the centre.
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IF NO, I UNDERSTAND THAT ON THESE DAYS THEY MAY NOT BE ABLE TO ATTEND WHEN OFF-SITE.

Parent/Guardian Initial:
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Attendance Policy
Children under the age of 12 are required to stay for the duration of the program unless alternate arrangements have been made with Program administrators or unless indicated below. Children under the age of 12 must be signed out of the program each day by any Parent/Guardian or Designated Emergency Contacts as listed on this registration form. If your child will be picked up by a non-designated person, an Alternative Sign-Out Form must be filled out by a designated guardian during drop-off. Alternative Sign-Out Forms can be obtained from the Recreation Leaders. Program administrators are not responsible for the supervision of children or their transportation outside of program hours.
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Parent/Guardian Initial:
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Release / Waiver
By signing below, I acknowledge that I fully understand the purpose of this program, the type of activities that my child will be participating in, and that I have received and reviewed the basic program schedule and layout. I understand that there are inherent risks with organized games and activities and I accept these risks. I agree to release, discharge and hold harmless the City of Brandon, its staff and agents and the program named above from and against all claims and proceedings with respect to any damage or injury to myself, and/or my child, and/or my property, arising from the provision of these services and activities.
Signatures/Authorization
Signature:
Click Here To Sign*
Print Name:
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Date:
Signature:
Click Here To Sign  
Print Name:
 
Date:
 
 
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THE FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT (FIPPA) & PERSONAL HEALTH INFORMATION ACT (PHIA)

The City of Brandon collects personal information and personal health information in the course of admission, registration, and related activities for the provision of its programs. This information is collected under the authority of The Freedom of Information and Protection of Privacy Act (FIPPA), The Personal Health Information Act (PHIA) and City of Brandon Policies and Procedures.

If you have any questions, please feel free to contact us at
204-729-2257 or recreation@brandon.ca

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