Healthy Teenz After-School Program 2025
Healthy Teenz will meet Tuesday Evenings from 5:00 PM - 6:30 PM
Sign in to Google to save your progress. Learn more
Beginning Tuesday January 7th, 2025
Information about Storm Days and School Cancellation
Please note: IF SCHOOL IS CANCELLED, THERE IS NO PROGRAM
Child's Name *
Address *
Date of Birth *
MM
/
DD
/
YYYY
Health Card Number *
Allergies and/or other medical information
Please specify any dietary restrictions and/or allergies (ex. Lactose intolerant, Celiac, Halal, Kosher, Vegetarian, etc.)
Parent/Guardian - Primary Contact *
Email Address *
Phone Number *
Emergency Contact - #1 *
Phone Number *
Relationship to Child *
Please Note: Family SOS will contact 911 for immediate medical emergencies. The emergency contact will only be contacted if the primary contact is unreachable. 
Consent of Participation and Program Policies
Family SOS provides programming for youth ages 5-17 years old and is committed to providing a safe and respectful environment. As part of this commitment, Family SOS does not tolerate any violent or inappropriate behavior toward other participants and/or Family SOS staff. Any inappropriate behavior will be discussed between the participant and the staff, and the primary contact will be expected to pick their child up from the program if inappropriate behavior continues after we have spoken to them.
I understand and agree to the terms and conditions stated above. 
*
Consent of Confidentiality  
Family SOS Healthy Kidz/Teens will ensure that all client information is kept confidential. When information is requested Consent to Release Information forms will be used, exclusions include Section 25 (Duty to Report) and Section 26 ( Order of Protection) of the Children and Family Services Act, S.N.S. 1990, c. 5.
As per the Children and Family Services Act S.N.S. 1990, c. 5, Family SOS has a duty to report any cases of suspected abuse or neglect of a child.
*
Photo Release
As the Parent/Guardian, I consent to my child having photos/videos taken of them while they are in the Family SOS Healthy Kidz/Teens after-school program. I understand that Family SOS has the unrestricted right to reproduce, use, exhibit, display, broadcast, distribute, and create works from these photos/videos for use in newspapers, social media channels, ads, publications, and any other business-related publications. I agree to grant the rights to such photos/videos to Family SOS, their employees, and board members. I will refrain from any claims, actions, or demands of defamation, invasion of privacy, copyright infringement, or any other person/property rights related to the use of the images taken.
*
Consent of Participation
As the Parent/Guardian I consent to the provided participant name attending the Family SOS Healthy Kidz/Teens after school program.
*
Declaration of Correct Information
I have read and agree to the terms and conditions stated in this registration form. I also declare that the information I have provided is true and accurate to the best of my knowledge.
*
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Family SOS.

Does this form look suspicious? Report