Building Bridges through Music Participant Registration Form

Transcription

1 SOCIAL DIVERSITY FOR CHILDREN FOUNDATION EMPOWERING YOUTH TO EMPOWER CHILDREN WITH DISABILITIES Building Bridges through Music Participant Registration Form Administration Use Only Registration #: Date of Registration: For the term schedule and registration deadline, please check the current Building Bridges through Music brochure or call the Social Diversity for Children Foundation at ext. 718 or visit the website at Returning participants will not need to fill out the registration form again. Please contact the Social Diversity for Children Foundation if you wish to continue the activity at your earliest convenience. Space is limited and acceptance is on a first come first serve basis upon fee payment, for both new and returning participants. Program Location: Byrne Creek Community School (Burnaby) th Street, Burnaby Strathcona Community Centre (Vancouver) Keefer St, Vancouver Full Name of Participant: Date of Birth: First Last MM/DD/YYYY Name of Current School: Grade: Name of Parent/Guardian: Relationship to Participant: Address: Street Address City Province Postal Code Home Telephone #: Work #: Cell #: Fax #:

2 Does your child have: Learning difficulties Physical disabilities Sensory problems Other (please specify): If yes, please provide details: (provide attachment if necessary) Is your child currently involved in a special education program at their school? Yes No If yes, please provide details: (provide attachment if necessary) Is your child receiving any other form of therapy? Physiotherapy Speech & Language Therapy Occupational Therapy Psychotherapy / Counselling Other (please specify): Is there anything else you would like to tell us about your child? (e.g. social interactions, does your child respond to music and sound, etc.) (Provide attachment if necessary) Parent/Guardian Expectations: Signature of Parent/Guardian: Date:

3 Participant Emergency & Health Form To Parents/Guardian: the information on this form will be used at the discretion of the activity instructor/coordinator to ensure care and attention is given to the safety and health of your child. All information on this form is considered Personal and Confidential. Please return this form to the responsible Social Diversity for Children Foundation staff. Participant Name: Date: Emergency Contacts (please provide two if possible, in order of contact order): 1. Name: Relationship to participant: Home Phone #: Work #: Cell #: 2. Name: Relationship to participant: Home Phone #: Work #: Cell #: Is your child on medication? Yes No If yes, please provide details: (Provide attachment if necessary) Does your child have any food allergies? Please give details, as snacks may be provided during the activity. Does your child have any other allergic reactions? If so, please list the type of reaction, treatment given, etc.

4 Waiver and Consent Form This waiver and consent form must be completed and returned to the Social Diversity for Children Foundation. One waiver form is required per participant, and is valid for all terms joined. Name of Participant (please print): Parent/Guardian Name (please print): Home Phone #: Cell #: I hereby give my full approval and permission for my son/daughter to attend the Social Diversity for Children Foundation's Building Bridges through Music program. I am aware that my child is expected to respect both the emotional safety and physical safety of other participants. Parents/Guardians will be informed if their child s behaviour does not reflect this standard. Any child who puts the safety of other participants at risk may be asked to withdraw from the activity. I agree to hold harmless al Social Diversity for Children Foundation staff, contractors, and volunteers, and the activity in-charge, and any parties hosting this event, including officers and directors, from any liability resulting from the participation of the named participant in the registered activity. WAIVER/RELEASE I agree and understand that the Social Diversity for Children Foundation and volunteers for this event ( organizers ) and its officers, and directors are not responsible for any loss, damage, personal injury, and death suffered by me, or my child, out of, or in connection with participation in this activity and/or any activity associated with this program, whatsoever and howsoever caused, including negligence on the part of the organizers. In consideration of the acceptance of my child at the activity, I agree on behalf of myself, my dependants, heirs, assigns and representatives to release, discharge and hold completely harmless organizers, it s owners, officers, and directors from any and all actions, claims, demands, liabilities, losses, damages, and expenses to my person or property, arising in relation to participation in this activity Parent/Guardian Signature: Date:

5 Photo Release Form The undersigned hereby grants to the Social Diversity for Children Foundation permission to take still photographs and moving films of myself/son/daughter/ward, Participant Name: and consent and authorize the Social Diversity for Children Foundation to use and reproduce all media material including pictures and films, in paper media, broadcast media, brochures, pamphlets, materials and books. With respect to the foregoing material, no inducements or promises have been made to the undersigned to secure signature to this release other than the intention of the Social Diversity for Children Foundation to use or allow use of such pictures or films for the primary purpose of promoting and aiding the Social Diversity for Children Foundation and its related work. Signature of Participant/Parent/Guardian: Printed Name: Date:

6 Payment Form Cash, credit, and cheques will be accepted as payment for the Building Bridges through Music Program. Please complete this form to complete the payment process. The cost of this program is $80 CAD per participant. Cash Cash Payments will be accepted by Serena Li or Ada Ru. Please contact them to schedule a pick-up of payment. serena@socialdiversity.org or 1 (888) Ext. 718 ada@socialdiversity.org or 1 (888) Ext. 711 Cheque Please address all cheques to the Social Diversity for Children Foundation. Cheques may be mailed to PO Box Richmond, BC V6X 8H3 Credit Card Information Cardholder Name: Card #: Expiration: / MM / YY CVC #: Billing Information Billing Address: street address city province postal code Phone #: