Afterschool Online Registration form – North Lambton Community Health Centre

Program Site

ICAN Forest
Aamjiwnaang

NLCHC Afterschool Program Walking Bus

Purpose

The Afterschool Program Walking Bus has been created to help ensure all children have the opportunity to participate in the Afterschool Program by being able to get from school to the program safely. Two NLCHC staff will lead the Walking Bus each day the program is offered.

Risk Reduction

The Afterschool Walking Bus is designed to reduce the potential risks involved in children walking unsupervised through high-traffic areas. The Afterschool Program participants will have safety in numbers and supervision during the walk by NLCHC Staff. Parents/Guardians are required to pick up their children up at the program site by 6:00 p.m.

Voluntary Consent

I certify that I have read this consent form, or it has been read to me; have been given the opportunity to ask questions; and that I understand the potential risks. By signing this form, I agree to allow my child to participate in the Afterschool Program Walking Bus. I also understand and agree that although supervision is provided for the purpose of having my child walk safely from the school to the Afterschool Program, the behavior of my child to follow supervision is the sole responsibility of me and my child. I have explained to my child the need for responsible behaviour and accept that should my child not follow the instructions of the leaders of the Walking Bus, he/she will not be allowed to be part of the After School Program Walking Bus.

Emergency Contact

I understand that should my son/daughter become ill or is injured during the Walking Bus trip to the After School program, someone will attempt to contact me or an emergency contact at the numbers listed below.

Parents Name*

First Last

Phone Number*

Emergency Contact*

Children Names

First Last

Children Names

First Last

School

Grade

Parent Email

Consent of Parent or Legal Guardian*

I agree/Consent

If I cannot be reached, I understand and agree that my son/daughter may be taken for medical assistance and I agree that I will be solely responsible for any and all costs incurred as a result. In exchange for my child being permitted to participate in the NLCHC Afterschool Program Walking Bus for my child, myself, my child’s heirs, guardians and legal representatives I release, hold harmless and agree not to make any claims of any kind against the Afterschool Program and the North Lambton Community Health Centre, or officials, staff, volunteers, employees, representatives, officers and directors for any injury (including death) to my child arising out of my child’s participation in these or related activities.

Date of Consent*

Afterschool Strategy Participant Consent & Emergency Information

Participant’s Name*

First Last

Date of Brith

School

Grade

OHIP

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Parents/ Guardian

Name

First Last

Relationship to Child

Home Phone

Cell

Name

First Last

Relationship to Child

Home Phone

Cell

Please list any Allergies or Medical Information we should be aware of, (i.e. food allergies, asthma, diabetes, etc).

Please list any learning or mental health concerns we should be aware of, (i.e. ADD, ADHD, Aggressions, Autism, etc).

Emergency Contacts: TWO contacts other than parents / guardians, is MANDATORY

Name*

First Last

Relationship to Child*

Home Phone

Cell

Name*

First Last

Relationship to Child*

Home Phone

Cell

Please list other individuals who CAN pick up your child from the program.

Name

First Last

Relation to Child

Name

First Last

Relation to Child

Please list any individuals who CANNOT pick up your child from the program.

Name

First Last

Relation to Child

Name

First Last

Relation to Child

Date

Understanding of Respect*

I agree/Consent

On behalf of myself and my child participating in the program, I understand and agree with the need for mutual respect of all those participating in the program, including staff, volunteers, and other participants. This is a group program led by trained leaders who monitor the whole group, thus are unable to provide continuous, direct, one-on-one monitoring for any one particular participant. I understand and agree that if the behaviour of my child is disrespectful and/or becomes a hazard to the health, safety, and wellbeing of others, my child may be asked to leave the program for a period of time or indefinitely.

Waiver of Responsibility*

I agree/Consent

Please inform your child’s health care provider that your child is attending the program. The North Lambton Community Health Centre cannot be held responsible for risk willingly assumed. Therefore, I hereby release the North Lambton Community Health Centre from damages, claims, and demands arising by reason of participation in the program.

Waiver of Damages*

I agree/Consent

I agree to take responsibility for any damages my child incurs to property of other program participants, of the program itself, and/or to the facilities in use.

Permission to Photograph / Video*

I agree/Consent

agree to allow the North Lambton Community Health Centre (NLCHC) to photograph and/or video my child during his/her involvement with the Afterschool Program. I understand that these photographs and/or videos may be used by the NLCHC in any form (i.e. website, social media, brochures, pamphlets, facebook, videos, etc.) or may be shared with third party organizations, (i.e. funders, community partners, LHIN, etc.) to describe and promote the NLCHC’s work in the community.

Does your child have permission to be in photographs and/or videos for reasons explained above?

Yes
No

Does your child have permission to walk home?

Yes
No

Does your child have permission to sign themselves in and out every day if you do not drop them off or pick them up?

Yes
No

I agree / Consent*

I am providing accurate information to the best of my knowledge.

Date of Consent

Registration Form - Programs

Which language are you most comfortable speaking?

English
French
Other

If other please specify

Which gender best describes you?

Female
Male
Intersex
Trans - Female to Male
Trans - Female to Female
Two - Spirit
Do not Know
Prefer not to answer
Other

If other please specify the gender.

Which sexual orientation best describes you?

Bisexual
Gay
Heterosexual
Lesbian
Queer
Two - Spirit
Do not know
Prefer not to answer
Other

If other please specify sexual orientation

Which racial or ethnic group best describes you?

If Mixed Heritage please specify

If other please specify your ethnicity

Where were, you born?

If born outside of Canada, in what year did you arrive in Canada?

Do you have any of the following? Check ALL that apply.

Which priority populations best describes you? (choose one)

Aboriginal
Age Group - Senior
Age Group - Youth
Poverty / Low income
Racialized
Rural

What is the highest level of formal education you have completed?

If other please specify you highest level of formal education completed

Approximately how much is the yearly income received by everyone in your household?

How many people are supported by this income?

Which of these options best describe the people who live in your household?

If other please specify the household composition

How would you describe your sense of belonging to your community? (Sense of belonging is feeling like you are part of something, connected and accepted)?

In general, what would you say your overall physical health is?

In general, what would you say your overall mental health is?