Afterschool program 2023-2024: Crouch Neighbourhood Resource Centre
The Crouch team is excited to work with neighbourhood children and youth this school year. There is no cost to participate in this afterschool program, but spots are limited and pre-registration is required. 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 participant.

- The Crouch Team
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Email *
Section 1: PARTICIPANT INFORMATION
First Name *
Last Name *
Preferred name
Primary language
Date of Birth *
MM
/
DD
/
YYYY
Pronouns *
Address (with Postal Code) *
Phone Number *
Grade *
School
Section 3: PARENT/GUARDIAN INFORMATION
All information below relates to you, the parent/guardian. Accurate and current information is required.
First and Last Name *
Preferred name
Parent/Guardian Email *
Relationship to the child/youth *
Address (with Postal Code) *
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?
Emergency contact  (must be different from primary contact)
First and Last name *
Relationship to the child/youth *
Phone Number *
Can we text the above phone number? *
Section 4: CHILD'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 3: ARRIVAL AND DEPARTURE INFORMATION
Parents/Guardians are responsible for the safe arrival and departure of their children/youth under the age of 16.
How will the child/youth participant depart program? *
If there are other people who can pick up your child, please list them here with their first and last name with a contact number
Section 5: PARENTAL/GUARDIAN DECLARATION AND ATTESTATION
This section will be for your digital signature for your child. Each question must be answered for your child to participate in Crouch afterschool programming.
I, the parent/guardian, give permission for my child to attend off site activities with staff supervision. *
I, the parent/guardian, give permission for my child to use public transit with staff to travel to off site programming. *
I, the parent/guardian, give the Crouch Staff permission to take pictures of my child/youth for social media and promotion of the programs that they attend. *
Is there anything else you would like us to know about your child/youth?
A copy of your responses will be emailed to the address you provided.
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