Youth Empowerment

Name*

First Last

Gender*

Male
Female
Other

Date of Birth

MM/DD/YYYY

What grade are you currently enrolled in?*

Grade 6
Grade 7
Grade 8
Grade 9

Which location are you registering for?*

Which session date are you registering for?*

Regina (March 31 - May 30)
Moose Jaw (February 27 - April 17)

How did you hear about the Youth Empowerment program?

Parent/Guardian Information

Main Contact: Parent/Guardian Name*

First Last

Address*

Street Address City Province Postal Code

Parent/Guardian Phone*

Parent/Guardian Email*

Alternate Parent/Guardian Name

First Last

Alternate Parent/Guardian Phone

Alternate Parent/Guardian Email

Preferred contact method

Text
Email

Group reminders, activities, etc.

Emergency Contact

Emergency Contact*

First Last

Phone*

Relationship to Participant*

Emergency Contact (additional)

First Last

Phone

Relationship to Participant

Please list any special transportation instrutions (e.g. youth will be transported via cab) or any persons NOT authorized to remove your child from Youth Empowerment Program.

Participants Medical Information

Does your child have allergies?*

Yes
No

Please list their allergies*

Does your child carry medication for their allergies?*

Yes (If yes, parents/guardians must complete a medication release form on participants first day )
No

Release of Liability and Assumption of Risk Waiver

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 Boys Empowerment Program 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 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.

Acceptance

Consent*

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*

By checking this box and typing my name below, I am indicating my name below, I am indicating consent on this form.

Name for form consent*

(First and last)