Community Connections E-Summer Program-Registration Form
Date of Birth (dd/mm/yyyy)*
Date Format: DD slash MM slash YYYY
PARENT / GUARDIAN INFORMATIONParent/Guardian Name*
Relationship to Participant*Phone*Email*
Address Line 2
AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
Status in Canada*Permanent ResidentConvention RefugeeCanadian CitizenOtherE-Summer Program FEEDBACK
How did you find out about this program?
HMC Staff or Settlement Worker
Friend or Family
Emergency ContactEmergency Contact Name
Emergency Contact Phone NumberConsentLIABILITY WAIVER FORM AGREEMENT*
I give permission for my child mentioned above to partake in all activities of the Art 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.
*Art House, SAVIS, YMCA of Oakville & City of Burlington
CONSENT FOR RELEASE OF INFORMATION*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. YesNoMEDIA/ELECTRONIC/PRINT/PUBLICATIONS/COMMUNICATIONS RELEASE FORM*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.
YesNoSIGNATURESPARTICIPANTS 18 YEARS AND OLDER CAN SIGN THE REGISTRATION FORM THEMSELVES.
PARTICIPANTS 17 AND UNDER MUST HAVE THEIR PARENT/GUARDIAN SIGN THE FORM.Date*
Date Format: MM slash DD slash YYYY
Signatures*By typing my name below, I confirm that I have read and understood the information above.