YMCA Beyond the Bell™ Inquiry Form

What school does your child attend? *

Participation Information

Please tell us about your child.

Full Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Home Phone Number *

Family Email Address *

Gender *

Female
Male
Prefer not to say

What grade is your child in? *

2
3
4
5

What is your child's birth date? *

Parent/Caregiver Information

Please provide us with the following information.

Full Name *

What is your full name?

Primary Phone Number *

What is your primary phone number?

Alternate Phone Number

Do you have an alternate phone number?

Full Name

What is your full name?

Primary Phone Number

What is your primary phone number?

Alternate Phone Number

Do you have an alternate phone number?

Alternative Contact & Authorized to Pick-up

Please provide us with contact information if the Parent/Caregiver cannot be reached.

Full Name

Phone Number

Relationship

Full Name

Phone Number

Relationship

Please provide us with the full names of any additional people who are authorized to pick up your child.

These are individuals that can pick up the child listed above in addition to the parent/caregivers and alternate contacts you have listed. All individuals picking up the child must be at least 16 years old and be prepared to show valid, government-issued, photo identification. (One full name per line.)

Academic Information

Please provide us with information about the following questions.

Does your child receive any additional support in school? If yes, please describe below.

What do you hope your child will accomplish while participating in this program?

Informed Consent

Please read the following in full and tell us if you give consent for the following statements.

Informed Consent *

I have read the program information provided and am aware of the program days and times, depending on the location my child is attending. I also understand that program schedules are subject to change with short notice. *
I understand that my child will be picked up from the location promptly at the end of each session, depending on location and as indicated in the program information provided. I also understand that my child must be picked up by a parent/caregiver or approved alternate listed above and that they will be required to show valid photo identification every day. I am aware that any change in the approved pick up list must be communicated to the Beyond the Bell™ team prior to pick up. *
I acknowledge that I am responsible for informing Beyond the Bell™ staff in advance whenever my child will be absent from the program. I agree to notify staff by calling or texting the program site phone if my child will not be attending on a scheduled day. I understand that if I do not provide advance notice, program staff will contact me or my alternate contacts to confirm my child’s absence. *

I give permission for my child to be a model for the YMCA of Niagara and I hereby assignall rights of the film/photography/videotape/sound recordings to the YMCA I authorizethe use of the same by the YMCA of Niagara and those acting with its permission for thepurpose to use, re-use and/or broadcast and republish said photograph/recording.

Yes
No

Consent to Participation *

I have read the program information and freely agree to allow my child to participate in all aspects of the program. I understand that my child will need to follow the behaviour guidelines and attendance expectations. I understand the measurement completed in the program and consent for my child to participate as a program participant. I release the YMCA of Niagara and the District School Board of Niagara from all liability related to my child's participation. I confirm that the information provided above is accurate and complete. I confirm that my child is able to participate in the activities and the staff ratio described.

Consent to Share Information *

I hereby give permission to the YMCA of Niagara to share information gathered through registration and participation in the YMCA Beyond the Bell™ program pertaining to my child with Lincoln Centennial Public School. I give permission for Lincoln Centennial Public School to share appropriate information with the YMCA of Niagara. I understand that due to the nature of the YMCA Beyond the Bell™ program, information shared between the YMCA and the School will likely include, but not be limited to, academic information. I understand that by registering my child for the YMCA Beyond the Bell™ program I am freely giving permission for relevant information to be shared in a confidential manner between the YMCA and the School in order to facilitate proper care, support and participation for my child.

Comment or Message

Signature of Parent/Caregiver *

Clear Signature

I understand that entering my name electronically and submitting this registration isconsidered the equivalent of a physical signature. I freely accept all information includedin this registration form.