KYAC Registration Form

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It is the responsibility of the parent and/or participant to notify the program coordinator of any changes to the following information.

First Name *

Last Name *

School *

School child will be attending during 2018-2019 school year

Date of Birth *

MM/DD/YYYY

Address *

Postal Code *

Parent/Guardian Names *

Home Phone Number *

Work Phone Number

Cell Phone Number

Emergency Contact *

Emergency Contact Phone Number *

Relationship to Participant *

Manitoba Health Number *

6 Digit

Manitoba Health I.D. Number *

9 Digit

Does your child have any severe allergies that require the use of an Epi-Pen? *

Yes

If "yes"please describe...

Please indicate any other information you feel we should be aware of?

(ex:medications, allergies etc.)

Image Release Permission *

This release is for the use of all members of the Kildonan Youth Activity Centre. It will remain in effect from the time of signing until the participants reach the age of majority. This information will be kept on file with the Kildonan Youth Activity Centre. In the course of activities, representative of the Kildonan Youth Activity Centre, participants and staff may take photographs or otherwise record events. These photographs and recordings are sometimes used to promote programming. Please advise us if you are willing to have your child/ward’s image and voice used for promotional purposes by KYAC, as indicated: I, on behalf of my child/ward, give permission to the Kildonan Youth Activity Centre to photograph and record my child/ward’s image and voice on still photographs, motion picture film, audio tape, video tape or digital media and to use this material, and/or similar material provided to KYAC by me or third parties involved in youth events, in whole or in part, now and in the future, through the media of television, film, internet, multi-media presentation, radio, audiotape, videotape, in printed and display form for the promotion of KYAC. I, on behalf of my child/ward assign and transfer to the Kildonan Youth Activity Centre any and all proprietary rights, including copyright, and waive all personality rights, which my child/ward may have in this material. The Kildonan Youth Activity Centre is only responsible for official uses of photographs and recording. Any personal uses by staff, participants, and non-participants outside of the promotional uses outlines above are not monitored by or the responsibility of KYAC.

Yes - I give permission as set out above

No - I do NOT give permission as set out above

Informed Consent Agreement *

I, the undersigned, hereby acknowledge that certain risks of injury are inherent to participants in sports and recreational activities. These types of injuries may be minor or serious, and may result from one’s own actions, the actions or inactions of others, or a combination of both. I understand that certain rules and regulations are designed for the safety and protection of participants and hereby undertake to abide by these rules and regulations set by KYAC. I understand that certain activities require a minimum level of health and fitness (physical, mental, and emotional) and that each person has a different capacity for participating in these activities. In addition, I recognize my own personal limits and will not push myself beyond these limits. Participants are responsible for choosing only those activities that meet their individual skill levels. I agree that the Kildonan Youth Activity Centre, or its staff members shall not be liable for any injury to my person, or loss or damage to my personal property arising from, or in any way resulting from, my participation in these activities, unless such injury or damage is caused by the carelessness of the Kildonan Youth Activity Centre, or staff members. I also hereby recognize that the Kildonan Youth Activity Centre is operated on a drop-in basis and only those participants and their guardians who are comfortable with this type of setting need participate. KYAC staff are not responsible for keeping participants on the premises if they so choose to leave and do not take responsibility for their actions or safety once they have left the specified area. I am also aware that KYAC staff reserves the right to ask participants to leave if they are disrupting the group or not following any of the KYAC rules and regulations as seen on the Kildonan Youth Activity Centre website. Parents/guardians please type your name below once you have read & agree to the above informed consent:

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