Dunnville Youth Impact Centre Fall/Winter Programs 2023/24 Registration
When: Programs will take place from October 3th, 2023 - May 30th, 2024
Contact us at (905) 774-6233 or info@dunnvilleyouthimpact.com
Website: www.youthimpactcentre.com

* Every participant must fill in their own form *
Sign in to Google to save your progress. Learn more
Email *
What grade are you currently in?  *
I am registering for - Click all that apply:  *
Required
Participant Name (First & Last) *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Home Phone *
Parent/Guardian Email *
Emergency Contact Name *
Emergency Contact Relationship to Participant *
Emergency Contact Phone # *
Any allergies, dietary restrictions or medical conditions we should be aware of? *
Is your child bringing any medication with him or her? (Antibiotics, ventilator, epipen, Ritalin)(Note: YIC staff or volunteers will not be responsible for giving or applying any medication) *
If your child will be bringing medication, please explain:
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of? *
Do you give the Dunnville Youth Impact Centre permission to use pictures of your child for display (ie- on our website, flyers or social media?) *
By typing your name, you agree to having your child participate in the above mentioned programs. Precautions are taken for the safety and health of your child, but in the event of accident or sickness, YIC, its board, its employees and its volunteers are hereby released from any liability. In the event that your child requires special medication, x-rays or treatment, the parents/guardians will be notified immediately. *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms