Child's Name
Age
Date Of Birth
Health Card #
School
Parent / Guardian
Relation
Home Address
City
Postal Code
Primary Phone #
Secondary Phone #
Email
Family Doctor
Doctor's Phone
Emergency Contact #1
Realtion
Emergency Contact #2
If there is anyone who is NOT to pick up or have contact with your child please provide us with their names to ensure the safety of your child:
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). If your child needs an EPI Pen or puffer please make sure they have it with them at all times. PLEASE DO NOT SEND MEDICATION OF ANY KIND TO SIMCOE HALL WITH YOUR CHILD.
Please provide any additional information that will help us provide your child with the best care possible (known allergies, Learning disabilities, ADHD, FASD ETC.):
I give consent for my child(ren) to participate in the Children’s After School Program Activities at Simcoe Hall Settlement House. I further agree to indemnify and hold harmless Simcoe Hall Settlement House, 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 Settlement House 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 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 for such programs. I agreeI do NOT agree
I give consent for my child to be photographed or videotaped for the purpose of our archival records (Photos taken to record special events or activities such as a children’s outing, play production, sports or dance performance), community relations or program display boards for an agency open house. Children will NOT be identified by name in ANY photo or video. I understand that special parent/guardian permission or consent is required for photos that may be taken or used in public media i.e. local newspaper or television. Parents would be contacted beforehand to sign an additional consent form. I agreeI do NOT agree
How will you be paying?ChequeE-TransferIn Person
