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HOMEBASE Program Registration

A new registration form must be completed at the time of registration.

HOMEBASE Registration

"*" indicates required fields

Youth Information

Youth's Name*

First Last

Preferred Name

First

Youth's date of birth*

Pronouns

Home Address*

Street Address City Postal Code

Phone*

Email

Emergency Contact Information

Emergency Contact Name*

First Last

Relationship to Youth*

Emergency Contact Phone*

Alternate Phone

Program Information

Please select from the drop down which program you are registering for*

Health Card Number*

Cooking Classes with MJFS*

Friday, August 15 - Chicken quesadilla & fruit salsa

Friday, August 22 - Pizza buns & chocolate no bake cookies

Friday, August 29 - Homemade ramen & grilled cheese

Youth can only register for one scheduled cooking class to give an opportunity for more youth to participate

Basecamp - A Youth Game Camp*

Summer 2025 (August 5 - 26) | 1 PM - 3 PM

Basecamp is a 4-week program every Tuesday in August.

General Information

Do you have any allergies we should be aware of?*

Yes

No

Allergies*

Is there anything else you'd like to share about yourself?

Yes

No

Please use this space to share anything about yourself*

Do you have any career goals / personal goals that you want to achieve by participating in the course or program?

Yes

No

Please use this space to share your goals*

Acceptance

Consent

I acknowledge that I am over the age of 18

Consent

Participants under the age of 18 require Parent/Guardian consent to participate.

Parent/Guardian Name

First Last

Release of Liability

In consideration of participating in any program or service, the YMCA/HOMEBASE the undersigned agrees, understands and appreciates that:

1.*

There is a potential for the risk of injury from participating in this program, and while particular rules, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist.*

2.*

ALL SUCH RISKS ARE KNOWINGLY AND FREELY ASSUMED, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and Participant assumes full responsibility for participation.*

3.*

Participant willingly agrees to comply with the stated and customary terms and conditions for he/she/they will remove himself/herself/themself from participation and bring such to the attention of the nearest YMCA representative immediately.*

4.*

Participant hereby, in his/her personal capacity, and also as parent and/or guardian the Participant, and on behalf of heirs, assigns, personal representatives and next of kin, HEREBY or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and leasers of premises used to conduct the event (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.*

Photo Permission

I hereby consent to and authorize the use and reproduction by, the YMCA/HOMEBASE or anyone authorized by the YMCA/HOMEBASE, or any or all photographs/content/text which you have taken of me today whether staged or candid. This is without compensation to me, or anyone for use by the YMCA of Regina/HOMEBASE (and associated programs). I am aware this content can be used for any purposes authorized by the YMCA/HOMEBAE, including but not limited to: social media, website use, editorial publications, and printed advertising. All digital flies, together with the prints will remain the sole property of the YMCA of Regina/HOMEBASE. Furthermore, I understand that I will not be given the opportunity to inspect or approve the finished products or the printed matter/materials that may be used in connection therewith.*

Yes, I consent

No, I do not consent

Contact Us

YMCA of Regina

Phone: (306)757-9622
Email: info@regina.ymca.ca

Childcare Inquiries
Please visit our Childcare Section

Homebase Moose Jaw
For more information on how you can be involved, please contact: jill.lesuk@mjymca.ca

Charitable Registration Number:
11930 7155 RR0001

Visit us

Administration
3801 B Albert Street
Regina, SK S4S 3R4

Health, Fitness & Aquatics Centre
5939 Rochdale Blvd
Regina, SK S4X 2P9

Homebase Moose Jaw
52 High Street W (main floor)
Moose Jaw, SK S6H 1S3

Moose Jaw Community Programming
1250 11th Ave N.W
Moose Jaw, SK S6H 4L9

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HOMEBASE Program Registration

HOMEBASE Registration

Youth Information

Emergency Contact Information

Program Information

General Information

Acceptance

Consent

Release of Liability

Photo Permission

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