YMCA Beyond the Bell™ Inquiry Form

Thank you for your interest in YMCA Beyond the Bell! Please complete the registration form below in full so we can better get to know your child. If you have any questions, please contact us at [email protected].

Step 1 of 6

School *

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 the YMCA is taking the necessary steps based on Provincial and Public Health recommendations to mitigate the spread of COVID-19, and that the YMCA can in no way be held responsible for any illness or virus that a participant may contract. I understand that I am to keep my child home if they or any member of my family has tested positive for COVID-19 in the last few days, is awaiting testing or awaiting advice from Public Health or a family doctor as a result of symptoms. *
I understand that, for the purposes of COVID-19 contact tracing, pertinent information about my child may be shared with Public Health or other lawful agencies, if requested, as required by provincial regulations. *
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 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.

Consent to Participation *

I have read the program information and freely agree agree to allow my child toparticipate in all aspects of the program. I understand that my child will need to followthe behaviour guidelines and attendance expectations. I understand the measurementcompleted in the program and consent for my child to participate as a programparticipant. I release the YMCA of Niagara and the District School Board of Niagara fromall liability related to my child's participation. I confirm that the information providedabove is accurate and complete. I confirm that my child is able to participate in theactivities and the staff ratio described..

Consent to Share Information *

I hereby give permission to the YMCA of Niagara to share information gathered throughregistration and participation in the YMCA Beyond the Bell program pertaining to mychild with Lincoln Centennial Public School. I give permission for Lincoln CentennialPublic School to share appropriate information with the YMCA of Niagara. I understandthat due to the nature of the YMCA Beyond the Bell program, information sharedbetween the YMCA and the School will likely include, but not be limited to, academicinformation. I understand that by registering my child for the YMCA Beyond the Bellprogram I am freely giving permission for relevant information to be shared in aconfidential 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 *

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.

YMCA Beyond the Bell™ Inquiry Form

Participation Information

Parent/Caregiver Information

Alternative Contact & Authorized to Pick-up

Academic Information

Informed Consent