Summer Mentorship in Moose Jaw | Session 2 "*" indicates required fields Youth InformationYouth's Name* First Last Youth's Gender* Male Female Other Youth's date of birth*Which week of Mentorship are you registering for?* August 4th - August 6th August 10th - August 13th August 24th - August 27th Parent/Guardian InformationMain Contact: Parent/Guardian Name* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Parent/Guardian Phone*Parent/Guardian Email* Alternate Parent/Guardian Name First Last Emergency Contact/Authorized Pick-up InformationEmergency Contact/Authorized Pick-up* First Last Phone*Relationship to Participant*Emergency Contact/Authorized Pick-up First Last PhoneRelationship to ParticipantParticipant's Medical InformationSaskatchewan Health Card Number*Does your child have allergies?* Yes No Allergies* Add RemoveDoes your child carry medication for their allergies?* Yes (If yes, parents/guardians must complete a medication release form on the participant's first day ) No Describe any physical/medical conditions that may restrict your child's participation in program activities. How can staff best assist your child during program activities?*Please enter N/A if not applicableRelease of Liability and Assumption of Risk WaiverPick Up Policy* I understand that the YMCA of Regina requires parents/guardians and authorized individuals to produce valid Government issued photo I.D to verify identity at the time of pick-up.*Release of Liability and Assumption of Risk Waiver* I understand that the YMCA of Regina assumes no responsibility for injuries or illnesses which I, my spouse/partner, or my minor children or any other person may sustain as a result of my/their physical condition, this program, my/their use of any facility or my/their participation in any activities, programs, exercise, or use of any equipment (collectively, "Activities"). I expressly acknowledge on behalf of myself, my spouse/partner, my minor children and our heirs that I assume the risk for any and all injuries, illnesses, death, loss or damage which may result from any of the foregoing. I herby release and discharge the YMCA of Regina, its agents, servants, and employees from ay and all claims for injury, illness, death, loss or damage which I, my spouse/partner, or minor children may suffer as a result of their physical condition, this program, the use of any facility, or participation in any Activities. Participants are prohibited from possessing or using alcohol, tobacco products, non-prescription drugs, and weapons of any kind. Participants must follow safety instructions of YMCA staff, and refrain from harmful behavior. Failure to comply with thes YMCA policies will result in immediate dismissal from YMCA programs without refund.*Consent* I consent to receiving communications from the YMCA Mentorship Administrators with regards to programming and schedule.*Consent* I understand that the YMCA of Regina is not responsible for personal property lost or stolen while members and/or program participants are using YMCA facilities, or are on YMCA premises.*Consent* I consent to my child participating in the YMCA Summer Mentorship programming that requires the use of a 15-passenger van.*Consent I give my permission to the YMCA of Regina to use indefinitely, without limitation or obligation, photographs, film, footage, or tape recordings which may include my, my spouse/partner's or minor children's image or voice for purposes of promoting or interpreting YMCA Programs.AcceptanceConsent* I acknowledge the Liability Waiver set forth above and being in agreement with the Mission and Goals of the YMCA, hereby apply for registration*Consent* I acknowledge that cancellations/withdrawals from this opportunity must be made 7 days before the Participant's first day*
