Child's Name
Date Of Birth
Grade
School
Address
Family Doctor
Health Card #
Caregiver #1 Name
Relationship to Child
Phone Number
Email
Caregiver #2 Name
Emergency Contact #1
Emergency Contact #2
My child will be participating in Simcoe Hall’s Walking Bus Program from Village Union P.S. I hereby give consent for Simcoe Hall Staff to speak directly with Village Union P.S regarding my child’s participation in the Walking Bus Program. I have read and understood the Walking Bus rules detailed on page 5. of the After-School Program Handbook. YesNo
I give authorization for the following people in addition to the Parents/Guardians and Emergency Contacts listed on the registration form, to pick-up my child from the After-School Program.
Name
Are there any court orders or custody restrictions which would prevent us from communicating with either parent/guardian? YesNo (If yes, we will contact you for additional information.)
Please be advised that Simcoe Hall Settlement House staff and/or volunteers are not permitted to store, handle or administer prescribed or over the counter medication. Special arrangements must be made for a parent/guardian or other assigned adult to administer any medication(s). PLEASE DO NOT SEND MEDICATION OF ANY KIND TO SIMCOE HALL WITH YOUR CHILD. The only exception to this rule applies to life-saving emergency and routine medication. If you child needs an EPI Pen or Puffer, please make sure they have it with them at all times and are aware of how to use it. For children with allergies please include the following information:
Type of Allergy
Symptoms and signs of an allergic reaction
Procedure to follow in the event of a non-life threatening allergic reaction
*If your child has an EPI Pen:
1. Please also include signs and symptoms of a life-threatening anaphylactic reaction.
2. The procedure to follow in the event of a life-threatening anaphylactic reaction.
Known asthma triggers
Signs and symptoms that the puffer may be needed
Procedure for emergencies related to asthma/asthma attacks
We kindly request that you provide any supplementary information that will assist us in delivering the utmost care to your child. This may include details such as learning disabilities, physical constraints, recognized triggers, and any diagnosed conditions (such as ADHD, FASD, ODD, ASD, etc.
Would you like your child to receive enhanced support? YesNo If yes, what areas would you like to focus on? We will contact you for more details if needed.
Please check the box below if your child is 12 years of age or older and you are giving them permission to walk home alone from Simcoe Hall. If your child has permission to walk home from our program they must call home and inform their guardian that they are leaving the program. If a parent/guardian does not answer the phone call on three or more occasions, then your child will no longer be allowed to walk home and a parent will have to come pick them up. This is for the children’s safety. I give consent for my child to walk home from Simcoe Hall as indicated above.I agreeI do NOT agree
I give permission for Simcoe Hall staff to give my child food or drink as part of the After School program. I agreeI do NOT agree
I give consent to Simcoe Hall Settlement House (“Simcoe Hall”) to use digital images and/or recordings of my child, obtained as follows: I give permission for Simcoe Hall Settlement House to use the digital images and/or recordings as stated above now, or in the future for the purposes of sharing via social media outlets (including but not limited to; Facebook, Instagram, Twitter, and LinkedIn), media advertising, public displays, public presentations, events, brochures or other third party publications, newsletters, and Simcoe Hall’s websites and newsletters. I agreeI do NOT agree
At times, both children and staff may spontaneously embark on walks to the local neighbourhood park. These outings might not always be prearranged. By signing this permission slip, you authorize Simcoe Hall to lead your child on a walk without prior notice. I agreeI do NOT agree
“I hereby give consent for my child to participate in the Children’s After School Program at Simcoe Hall” “I further agree to indemnify and hold harmless Simcoe Hall, its agents, employees, or volunteers of all liabilities for loss or damage arising from any cause whatsoever and hereby release, waive and discharge Simcoe Hall Settlement House from all liability to my heirs, executors, administrators, and assigns for all loss or damage any claim’s or demands for such loss or damage on account of injuries to person or property while participating in and or being transported to and from program activities.” I agreeI do NOT agree
“I hereby give permission to Simcoe Hall to provide or arrange for such first aid or other medical treatment or care of child included in this registration, including but not limited to transportation to the hospital, as such staff may consider necessary or advisable. I understand that all costs related to such actions shall be my responsibility and I agree to pay and/or reimburse Simcoe Hall Settlement House for any such cost as may be incurred.” “I accept full responsibility for ensuring that participants named in this registration application are physically and medically fit to participate in the program activities for which they are registered throughout the duration of such programs.” I agreeI do NOT agree
After-School Program (ASP) Membership: $220.00 per school year. For your convenience we offer two payment plan options: *Option 1: $220.00 (payment in FULL upon registration) *Option 1: two payments of $110.00 as mutually agreed upon between the program coordinator and payee.
Walking Bus - Village Union Public School only: $60.00 for the year. (must pay in full upon registration)
Payment can be made via cash, e-transfer, or credit card. Please note there is a 3.40% service fee for all credit card transactions. If paying by e-transfer please include a memo stating the fees are for the After-School Program as well as your child’s name. E-transfer: etransfersh@gmail.com Password: afterschool
Due to the reduced costs of our program, we do not offer subsidies or prorated fees.
Payment Option: Pay in Full (ASP Option 1/Walking Bus)Option 2 (ASP only)
Total Payment Amount:
Method of Payment:CashE-TransferCredit Card
I acknowledge that by choosing payment option 2 I am responsible for making the payment by the due date as stipulated in my payment option. If the payment obligation is not met by the agreed-upon dates, I understand that my child cannot attend the After-School Program, until payment is made
I confirm that I have read and comprehended the guidelines outlined in the After School Program Information Handbook. Yes I have read itNo I have not read it
