Afterschool Online Registration form – North Lambton Community Health Centre

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.

Phone Number(Required)

Emergency Contact(Required)

School

Grade

Parent Email

Afterschool Strategy Participant Consent & Emergency Information

School

Grade

OHIP

Home Phone

Parents/ Guardian

Relationship to Child

Home Phone

Cell

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

Relationship to Child(Required)

Home Phone

Cell

Relationship to Child(Required)

Home Phone

Cell

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

Relation to Child

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

Relation to Child

Registration Form - Programs

If other please specify

If other please specify the gender.

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?

If other please specify you highest level of formal education completed

How many people are supported by this income?

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?

Name

This field is for validation purposes and should be left unchanged.