Program Registration Form – Concern For Youth

Youth's Name *

First and Last Name

Date of Birth *

Month, Day, Year

Age *

Physical Address *

please include if you live in North Battleford, Battleford or a surrounding community.

Additional Addresses *

please include if you live in North Battleford, Battleford or a surrounding community.

City *

Postal Code *

Youth Contact Information - Phone Number/Email *

Health Card # *

Allergies / Medical Information *

School *

Elementary SchoolElementary School

Sakewew High School

John Paul II CollegiateJohn Paul II Collegiate

North Battleford Comprehensive High School

Not enrolled in classes at this time

Guardian Name *

Relationship *

Contact Information (Phone Number/Email) *

Guardian Name (Secondary)

Relationship

Contact Information (Phone Number/Email)

Emergency Contact Name (Other than parent) *

Emergency Contact Relationship *

Emergency Contact Phone Number *

Please identify any special needs your youth may have including physical, emotional, and/or behavioural. This information helps us to better meet the needs of the youth. *

Media Consent and Release

Yes

*Concern For Youth is asking if you give consent for us to share any photos of youth while participating in CFY programming evenings and events for the purpose of our social media use and pictures that are submitted to our funders. Youth 16 + are able to consent for themselves.

Media Consent and Release Name *

Media Consent and Release Date *

I, the parent/guardian of the above mentioned youth acknowledge the risks associated with my youth participating in any events, programs, and activities conducted by Battlefords Concern For Youth Inc (CFY).

Yes

I give permission to CFY staff to transport youth within the Battlefords Area and within 50 KM of the area. This includes rides home and rides to off-site programs.

Yes

I agree that CFY is not responsible for illness, injury, or loss to the youth and their property.

Yes

I acknowledge and understand the implications of this consent form *

By putting your name in this box you are legally acknowledging all of the above information on this form.

Date *

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