DOXA PREP: Academic Support and Mentorship for Grades 3-6

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Location: Bridletowne Park Church
2300 Bridletowne Cir, Scarborough, ON M1W 2L2

Fall session Launching Thursday November 16th- Dec 14, 2023

Weekly event times: Thursday from 4:00pm-5:30pm

*Program times are subject to change.

For more info contact Michael Morrison
Email: mmorrison@yugta.ca

A form completed by you is required before your child can participate. This is an important document. If needed, please ensure that someone translates and explains this document to you.
This is a legal document. The collection and retention of the information requested on this form is authorized and governed by the Freedom of Information and Protection and Electronic Documents Act (Canada).
By submitting this form I agree to receive updates from DOXA Toronto, Youth Unlimited and partner churches of DOXA Day Camp.

Email *

First and Last Name of Student? *

Student Date of Birth *

YYYY

First and Last Name of Parent(s)/Guardian(s) as well as Address or addresses. Please include any secondary email addresses if applicable. *

Please provide full names of emergency contact(s), relationship, and emergency contact phone number *

What school does your student attend? What grade is your student in? What subject/s do they need assistance with? *

Please list any behavioral or emotional concerns that we should be aware of to best care for your child. If there are no special needs please put N/A.
*

How will your child be getting to and from the program (check all that apply) *

I would like my child to be walked to the program from Brookmill Boulevard Junior Public School by a worker or volunteer

My child can walk to the program on their own

My Child can walk home on their own

I (the Parent/Guardian) or someone specified below will be picking up my child at 5:30pm (Program end-time)

Required

Health Card number (If applicable) *

Does your child have any allergies, food restrictions, medical concerns, or medications that they will be bringing with them. *

Who is authorized to pickup your child? We can only release your child to you or those you name specifically. (Please include full names and contact numbers) *

Do you have any comments or questions?

What other families would you recommend this program to? Please include name and contact number. Please also inform them that we will reach out within 48 hours.

By submitting this form, I hereby grant permission for the above named child to participate in DOXA PREP and to receive emergency medical care as directed by a physician if I cannot be contacted and she/he is in need of such care. I hereby release Youth Unlimited, Bridletowne Park Church, its staff, volunteers and sponsors of any responsibility and liability for any injury or illness that my child may sustain during her/his participation in DOXA PREP. I give permission to Youth Unlimited/Bridletowne Park Church to use photographs and any other media representation of myself and my family members at the discretion of either organization. I release Youth Unlimited and Bridletowne Park Church, its officers, directors, volunteers and its staff from any and all responsibility/liability that may arise as a result of the use of photos/media. I give permission for my child to receive food or beverages while present at the program. I authorize our vetted staff to provide rides for the children when needed.

Yes

Date Form is Completed *

YYYY

A copy of your responses will be emailed to the address you provided.

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