Community Connections Newcomer Youth Connect Leadership Program

Participant Information

Name(Required)

First Last

Date of Birth (dd/mm/yyyy)(Required)

Phone(Required)

Email(Required)

PARENT / GUARDIAN INFORMATION

Parent/Guardian Name(Required)

First Last

Relationship to Participant(Required)

Phone(Required)

Email(Required)

REQUIRED INFORMATION

Address(Required)

Street Address Address Line 2 City Province Postal Code

Whats your school name?(Required)

Name of your Settelment worker?(Required)

Whats your age?(Required)

Status in Canada(Required)

Please attach a photocopy of the front and back of your P.R. card/Conventional Refugee Document. *ONLY IF YOUTH HAS NOT JOINED AN HMC PROGRAM

OUTREACH FEEDBACK(Required)

How did you find out about this program?

Emergency Contact

Emergency Contact Name

First Last

Emergency Contact Phone Number

Consent

LIABILITY WAIVER FORM AGREEMENT(Required)

Consent

I give permission for my child mentioned above to partake in all activities of the Newcomer Youth Connect Leadership Program as planned by HMC Connections’ Community Connections Youth Program. The Halton Multicultural Council, and other community partners, therefore cannot be held liable for any accidents, injury, damage, or loss of personal possessions caused during the program activities both on and off-site. If applicable, I also give permission for my child to travel to and from tutoring sessions alone (e.g. public transit, on-foot). All the same, I understand that the Halton Multicultural Council, and other community partners, are not liable for the safety and wellbeing of your child under these circumstances. I understand all the risks and liabilities involved, and as such, agree to the terms and conditions above.

CONSENT FOR RELEASE OF INFORMATION(Required)

I, hereby authorize the HMC Connections to exchange & disclose my information internally with HMC programs. I have asked HMC for assistance and give full permission to disclose my personal information (if required) to IRCC & other applicable Service Providers for support, guidance, advocacy, information or referrals.

Yes

MEDIA/ELECTRONIC/PRINT/PUBLICATIONS/COMMUNICATIONS RELEASE FORM(Required)

I, the above named volunteer, student, employee, group, participant at the Halton Multicultural Council (HMC), unequivocally consent to the publication (including HMC social media accounts and website), release and transmission of the digital/electronic/print/photographs, to the extent that they may deemed necessary for express use thereof. This release and consent is voluntary. If you don’t wish to participate, there is no obligation on your part.

Yes

SIGNATURES

PARTICIPANTS 18 YEARS AND OLDER CAN SIGN THE REGISTRATION FORM THEMSELVES. PARTICIPANTS 17 AND UNDER MUST HAVE THEIR PARENT/GUARDIAN SIGN THE FORM.

Date(Required)

Signatures(Required)

By typing my name below, I confirm that I have read and understood the information above.