Community Connections Youth Road Safety and Driving in Ontario Program-Registration Form PARTICIPANT INFORMATIONName(Required) First Last Date of Birth (dd/mm/yyyy)(Required) DD slash MM slash YYYY Age(Required)1112131415161718PhoneEmail(Required) Parent / Guardian InformationParent / Guardian Name(Required) First Last Relationship to participant(Required)Phone Number(Required)Email(Required) Emergency ContactName(Required) First Last Phone Number(Required)Required InformationAddress(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Status in Canada(Required)Permanent ResidentConvention RefugeeCanadian CitizenOtherGrade(Required)6789101112Phone Number(Required)SPECIAL NEEDSDoes your child have any identified special needs?(Required)(Development or learning disabilities, mental health disorders, etc.) Yes NoOUTREACH FEEDBACK How did you find out about this program? HMC Staff or Settlement Worker School Friend or Family Brochure/Flyer/Poster Email/Newsletter OtherCONSENTLIABILITY WAIVER FORM AGREEMENT(Required) ConsentI give permission for my child mentioned above to partake in all activities of the Youth Tutoring Program as planned by HMC Connections. 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 (* Halton Public Libraries), 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 NoMEDIA/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 NoSIGNATURESPARTICIPANTS 18 YEARS AND OLDER CAN SIGN THE REGISTRATION FORM THEMSELVES. PARTICIPANTS 17 AND UNDER MUST HAVE THEIR PARENT/GUARDIAN SIGN THE FORM.Date(Required) MM slash DD slash YYYY Signatures(Required)By typing my name below, I confirm that I have read and understood the information above.
