EYI PROGRAMME REGISTRATION FORM
Programme Interest Form (R. 2020/22)
This is your opportunity to indicate your interest in registering for one of the programmes of the EMPOWER YOUTH INTERNATIONAL Charity #969.  This is classified as the official form of registration to our programmes platform.  

All parties are urged to provide as much and as accurate amounts of information as possible to ensure a smooth running process.  Once applications have been submitted allow, at least, up to two (2) weeks of processing, and further details will distributed in due course thereafter for any volunteer opportunities, which may arise.

Things to consider before indicating your interest as a programme participant:
1. What are my interest and goals in life?
2. How much time am I able to invest in reaching my goals? (i.e. attending courses, outreach events, etc.); and,
3. Am I going to be committed, coachable and consistant to implement what is taught to bring about a positive change in my life where necessary?

If any queries feel free to reach out via e-mail: info@empoweryouthint.org 

PLEASE NOTE: ALL INFORMATION PROVIDED WILL REMAIN CONFIDENTIAL AND WILL ONLY BE USED FOR THE PURPOSE OF MAINTAINING OUR DATABASE FOR UPDATED CONTACT OF ALL POTENTIAL MEMBERS.  THIRD PARTIES WILL NOT BE PRIVY TO THIS INFORMATION, UNLESS WE ARE ADVISED OTHERWISE BY YOU.  
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Which Programme are you interested in registering for? *
1. PERSONAL INFORMATION
PARTICIPANT NAME *
Please insert full name.
DATE OF BIRTH *
MM
/
DD
/
YYYY
SCHOOL ATTENDING *
PARTICIPANTS AGE *
No. of Years Old
T-Shirt Size *
PARTICIPANTS GENDER: *
NAME OF PARENT / GUARDIAN *
Please insert full name.
ADDRESS *
Please insert full postal / home address to allow for correspondence to be distributed to the same.
E-MAIL *
Please indicate the one most readily checked and accessible for both our convenience.
TELEPHONE (HOME) *
If applicable.
TELEPHONE (Work) *
If applicable.
MOBILE *
If applicable.
Please indicate which form of contact is more ideal for you: *
Required
Are you associated with any organizations or networks? Please list all below: *
If you have no affiliations please state "not applicable".
Please indicate which language(s) you speak: *
Required
2. MEDICAL AND HEALTH INFORMATION
MEDICAL AND HEALTH INFORMATION *
Please indicate if your child/ward has experiences any of the following:
Yes
No
Blood Clotting
Bowel Problems
Breathing Problems
Diabetes
Emotional Problems
Fainting Infections
Headaches
Hearing Problem
Heart Problems
Hyperactivity
Seizures
Sinus Trouble
Skin Problems
Sore Throats
Vision Problems
MEDICAL AND HEALTH INFORMATION *
Please indicate if your child/ward has had any of the following illnesses or allergies or allergic reactions:
Yes
No
Asthma
Hay Fever
Mumps
Tonsilitis
Chicken Pox
Insect Stings
Penicillin
Epilepsy
Measles
MEDICAL AND HEALTH INFORMATION
 Does your child/ward suffer from any ailment(s) listed above? If yes, please give details
MEDICAL AND HEALTH INFORMATION
 Does your child/ward suffer from any other ailment(s) not identified? If yes, please give details
MEDICAL AND HEALTH INFORMATION *
Yes
No
Does he/she suffer from any other ailment(s) not identified? If yes, please specify below
Is your child/ward on medication? If yes, please specify below
Does your child/ward have any disabilities? If yes, please specify below
MEDICAL AND HEALTH INFORMATION
Is your child/ward on medication? If yes, please specify below
MEDICAL AND HEALTH INFORMATION
Does your child/ward have any disabilities? If yes, please specify below
MEDICAL AND HEALTH INFORMATION *
Do you have family medical insurance? If yes, please state the name and address of the Company.  
3. DIETARY REQUIREMENTS:            
DIETARY REQUIREMENTS:             *
Please indicate if your child/ward is allergic to or does not eat any specific foods:
4. EMERGENCY INSTRUCTIONS
In case of an emergency, please notify:
NAME OF EMERGENCY CONTACT & RELATIONSHIP *
Please insert full name.
EMERGENCY CONTACT TELEPHONE (HOME/WORK) *
EMERGENCY CONTACT MOBILE *
EMERGENCY CONTACT ADDRESS *
Please insert full postal / home address to allow for correspondence to be distributed to the same.
DOCTOR'S NAME OR POLYCLINIC *
Please insert full name.
DOCTOR'S ADDRESS *
Please insert full postal / home address to allow for correspondence to be distributed to the same.
DOCTORS TELEPHONE *
If applicable.
PARENT'S MEDICAL AUTHORISATION *
This health history and medical information is correct to my knowledge.                                                                             I am aware that there is some inherent risk in activities at the programme and accidents sometimes occur.                                                                                             I hereby give permission for routine tests and treatment to be carried out by certified/trained personnel with my child/ward, in the event that I cannot be reached in an emergency.                                                                                       I also give my permission for trained officials to administer First Aid, call a doctor or seek emergency, medical/surgical care for my child/ward should an emergency arise.                                                                                   It is understood that our programme officials will make a conscientious effort to locate the emergency contacts listed on the registration form before any action will be taken.
Yes
No
I hereby give permission for routine tests and treatment to be carried out by certified/trained personnel with my child/ward, in the event that I cannot be reached in an emergency.
I also give my permission for trained our officials to administer First Aid, call a doctor or seek emergency, medical/surgical care for my child/ward should an emergency arise.
ACTIVITIES AUTHORISATION *
I hereby give permission for my child/ward to go on trips away from the programme premises, whether on foot or by vehicle.  I give permission for my child/ward to participate in all activities with the following exceptions:
Yes
No
I hereby give permission for my child/ward to go on trips away from the programme premises, whether on foot or by vehicle. I give permission for my child/ward to participate in all activities with the following exceptions
I hereby give permission for my child/ward to participate in all activities with the following exceptions:
I hereby give permission for my child/ward to participate in all activities with the following exceptions:
GENERAL INFORMATION
How did you hear about Empower Youth International? *
Required
Why do you wish to participate in this training programme? *
PARTICIPANT CODE OF CONDUCT
EYI Programme offers a safe and wholesome environment in which participants play and learn as part of a team.

Participants’ attitude and behaviour are critical to the success of the programme and each individual makes a difference in the quality of the programme experience.

Participants and parents/guardians must read and sign this agreement prior to programme attendance.  
PARTICIPANT CODE OF CONDUCT *
Please select and check box confirming you have read and understood the following:
Required
CODE OF CONDUCT (CONTINUED)
If a participant fails to abide by these behavioural expectations the parent/guardian will be notified and asked to assist in helping the participant make more positive choices.  If the participant behaviour does not improve, he/she will be asked to leave programme.  

The following behaviours are considered very serious and may result in immediate expulsion from programme:
1. Possession or use of weapons, elicit illegal drugs or other controlled substances, tobacco products of any kind and
       alcoholic beverages.
2. Physical abuse of any kind including hitting, biting or pushing another participant or staff member.
3. Failure to follow instructions thereby resulting in situations that put themselves, other participants or staff in physical
       danger.
4. Leaving the programme facilities without the permission of a staff member.
5. Verbal abuse of other participants or staff.
6. Behaviour that is constantly interfering with the quality of the programme.
7. Participants threatening to harm themselves or other participants.
PARTICIPANT CODE OF CONDUCT ACCEPTANCE *
I/We have read and understand these behavioural expectations and I agree to abide by them at all times during the programme period.
PARENTS' CONTRACT
I certify that the information given on this registration form is accurate.
I understand that no refunds are given in the event that my child/ward’s attendance comes to an abrupt end due to disruptive behaviour as decided by the Programme Director.  
I further agree to accept responsibility for any damage or injury incurred by my son/daughter/ward to property or possessions of staff or other participants and to make the necessary provision for repairs/replacements within one (1) week after the incident occurs.
I agree to give permission to use my child/ward photo for use  in EYI promotions.                                                                                                                                                                                                            
PARENTS' CONTRACT *
I have read and understand these behavioural expectations.  Furthermore, I have discussed these expectations with my child/ward and he/she has agreed to abide by them at all times during the programme period.
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