LEAD Registration

LEAD Registration Form

Registration is $50 to secure your child's spot.

Child Name

Child's Date of Birth

Child Age

Primary Parent Name

Parent Name (Secondary)

Address

Emergency Contact (1) Name

Emergency Contact (2) Name

Child's Grade

Primary Phone Number

Parent Phone Number (Secondary)

Emergency Contact (1) Phone Number

Emergency Contact (2) Phone Number

Non-Parent Pick Up Authorization

Known Allergies

Is the participant on medication?

Yes

If yes, what medication are they taking?

Does the participant require support/accomodations due to a disability?

Yes

If yes, please download Particpant Information Form and upload it here.

Upload Form

I, in my personal capacity and on behalf of the participant, do hereby RELEASE FROM ALL LIABILITY Alison Neighbourhood Community Centre, its Directors, volunteers, employees, agent and representatives (hereinafter Releasee) for any injuries, illnesses or other mishap that may be incurred by the participant while attending a registered or drop in program or event, except where damage or injury is caused by the gross negligence of the Releasee. In the event the participant should be injured or become ill, I authorize any medical treatment that may be required and will assume full financial responsibility for the said treatment

I hereby give my child permission to travel off-site to activities and events with the staff and volunteers on the above terms. Prior notice/schedules of activities will be provided. I authorize that I/my child may be digitally imaged for public relations material/purposes.

PHOTO RELEASE: I hereby give my permission to Alison Neighbourhood Community Centre and the Cambridge Neighbourhood Organizations for the unrestricted right to take, use and publish my photograph, video and likeness in publications, promotional materials, website and any other communication vehicles, including electronic forms, at its discretion

I hereby certify that the information provided is true and to the best of my knowledge.

Your Signature

Today's Date

Thanks for joining us! You will recieve a confirmation email within the next 24 hours with further information about the program.