Empowering Youth Employment

Name
This field is for validation purposes and should be left unchanged.
Participant Information
Name*
First Last
Preferred Name:
Date of Birth (dd/mm/yyyy)*
Phone*
Email*
PARENT / GUARDIAN INFORMATION
Parent/Guardian Name*
First Last
Relationship to Participant*
Phone*
Parent Email*
REQUIRED INFORMATION
Address*
City Province Postal Code
What's your school name?*
Name of your Settelment worker?*
What grade are you in?*
Status in Canada*
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
How did you find out about this program?
- HMC Staff or Settlement Worker
- School
- Friend or Family
- Brochure/Flyer/Poster
- Email/Newsletter
Emergency Contact
Emergency Contact Name
First Last
Emergency Contact Phone Number
Consent
LIABILITY WAIVER FORM AGREEMENT*
- Consent
I give permission for my child mentioned above to partake in all activities organized 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 in-person 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*
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
- No
MEDIA/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.
- Yes
- No
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*
Signature*

By signing below, I confirm that I have read and understood the information above.

PARENT / GUARDIAN INFORMATION

REQUIRED INFORMATION

Emergency Contact

Consent

SIGNATURES

Head Office - North Oakville

Burlington

Milton

Call us at 905-842-2486

STAY CONNECTED