Youth Leadership in Training 2022: Crouch Neighbourhood Resource Centre
The Crouch team is excited to work with neighbourhood youth this summer in a new and exciting leadership program! We will be following public health guidelines to ensure a safe environment for all participants. There is no cost to participate in this program, but registration is required. Programming will be facilitated at the Annex (898 Trafalgar Road) and at the Graham Family EcoPark in Arva (transportation will be provided). We will have lots of fun with art, sports, environmentalism, nutrition, community leadership and other activities based on participant interest.  All activity fees have been generously sponsored by Canadian Tire Jumpstart.

Please note that preference will be given to youth who reside in the Hamilton Road Neighbourhood. This form is an expression of interest only. Registration will be confirmed by a Crouch staff, pending available spaces. Please fill out one form for each youth.

Let's get this summer started!

- The Crouch Team
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Email *
Section 1: PARTICIPANT INFORMATION
First Name *
Last Name *
Date of Birth *
MM
/
DD
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YYYY
Pronouns *
Address *
Postal Code *
Phone Number *
Age *
If you are over 18 would you be able to get a police vulnerable sector check? (please let staff know if the cost is an issue)
Clear selection
School
Please select the weeks of camp that you may be available for (One shift every two weeks at a minimum)
What days of the week are you available?(Monday-Thursday 9:30 am-4pm, Friday 9:30am-12:30pm)
Section 3: PARENT/GUARDIAN INFORMATION (under 18)
All information below relates to you, the parent/guardian. Accurate and current information is required.
First and Last Name *
Parent/Guardian Email *
Relationship to the child/youth *
Address *
Daytime Phone Number *
Can we text this daytime number? *
If you answered "NO" to the above question, is there another number that we can text you at?
Section 4: EMERGENCY CONTACT  (must be different from primary contact)
please fill out this area if you are 18
First and Last name *
Relationship to youth *
Phone Number *
Can we text the above phone number? *
Section 5: PARTICIPANT'S MEDICAL INFORMATION
All Information below is related to your child/youth. Please fill in all information accurately as possible.
Doctor's Name *
Doctor's Phone Number *
Allergies or allergy related symptoms *
Medications presently being used, medical restrictions, and special needs *
Section 6: DECLARATION AND ATTESTATION
This section will be for your digital signature for yourself or your child. Each question must be answered for yourself or your child to participate in programming. PROGRAMMING WILL ALWAYS START AND END AT 898 Trafalgar Rd (the Annex). Programming will also be facilitated at different locations such as CNRA park, South Branch Park, Silverwoods Arena, and other community sites.  
I, the participant/the parent/guardian, am comfortable/give permission for my child to attend off site activities with staff supervision. This is a requirement of camp, as the majority of activities will take place off site. (example: EcoPark, Swimming, mini golf, bowling).   *
I, the participant/parent/guardian, am comfortable/give permission for my child to use public transit and a private bus to travel to off site programming. *
I, the particpant/parent/guardian, give the Summer Splash Staff permission to take pictures of myself/my child/youth for social media and promotion of the programs that they attend. *
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