CENTRE CHANTAL BÉRUBÉ COMMUNITY YOUTH CENTRE MEMBERSHIP FORM
(Youth must be between the ages of 12 and 17, no exceptions) PERSONAL INFORMATION: I ___________________________the parent/guardian of ________________________________, hereby provide (Name of Parent/Guardian)
(Name of Youth)
my consent for my Youth to participate in the Centre Chantal Bérubé Community Youth Centre programs/activities/fundraisers. As the parent/guardian may we contact you and/or your Youth by mail/phone/e-mail to participate in upcoming programs/activities/fundraisers? Yes__________________ No__________________ Youth’s First Name:
Middle:
Last:
Date of Birth/Age:
Sex: M
Home Phone Number:
Home Address:
Name of the Parent/Guardian:
Parent/Guardian Work and/or Cell Phone Number:
E-Mail Address:
Alberta Health Care Number:
F
Grade:
Any Medical Concerns:
EMERGENCY CONTACT: In the event of an emergency, if we cannot reach you, whom do we contact? Name Address Phone Number Relationship to youth Liability Clause: I agree that the Centre Chantal Bérubé Community Youth Centre will not be responsible for any injuries my Youth may sustain from/while participating in any Centre Chantal Bérubé Community Youth Centre activities/programs/fundraisers. Medical Waiver: I waive my legal right against the Town of Beaumont and the Centre Chantal Bérubé Community Youth Centre Staff/Volunteers for any loss, injury or damage suffered at any Centre Chantal Bérubé Community Youth Centre activities/programs/fundraisers. I hereby authorize Staff/Volunteers of the Centre Chantal Bérubé Community Youth Centre to have my Youth transported to the hospital for any emergency treatment that may appear necessary in the event that I cannot be contacted immediately. I further consent to pay any medical expenses incurred that are not covered by my health insurance plan. Parent/Guardian Signature: ________________________________
Date: ______________________
The personal information requested on this form is being collected under the authority of the Freedom of Information and Protection of Privacy Act (FOIP). The information collected will be used as required for becoming a member of the Centre Chantal Bérubé Community Youth Centre (CCBCYC). If you have any questions about the collection or use of your personal information, contact the Town of Beaumont’s FOIP Coordinator at 5600 – 49th Street, Beaumont, Alberta T4X 1A1, or Phone (780) 929-8782.
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Release of Information Form Due to the Freedom of Information and Protection of Privacy Act (FOIPP), we require written permission, from parents/guardians, for various activities/programs/fundraisers within the
Centre Chantal Bérubé Community Youth Centre.
At various times throughout the year we would like to have Staff/Volunteers of the Centre Chantal Bérubé Community Youth Centre contact you by phone for your participation with the following: service delivery surveys, fundraisers, and special events. Please complete this form as part of the registration process: I, ______________________________________, hereby give permission to the Parent/Guardian’s Name
Centre Chantal Bérubé Community Youth Centre to: Release my son/daughters full name to the Centre Chantal Bérubé Community Youth Centre for the purposes listed below: Display photos for others to see. To be published in the Media/Brochures to advertise the Centre Chantal Bérubé Community Youth Centre activities/programs/fundraisers. To be used on static display boards at community events to advertise the Centre Chantal Bérubé Community Youth Centre activities/programs/fundraisers. To attach to my youth’s membership form for Staff use. _____________________________________ Parent’s Signature
__________________________ Date
_____________________________________ Witness’ Printed Name (Over 18 years old)
__________________________ Date
_____________________________________ Witness’ Signature **VOLUNTEERS** are an essential part of the Centre Chantal Bérubé Community Youth Centre. Will you be a volunteer? Yes_____________
No_____________
I hereby give permission to release my full name and phone number to the Youth Centre Coordinator at the Centre Chantal Bérubé Community Youth Centre for the purpose of volunteering and recognition events. ______________________________________ Parents Signature
________________________ Date
If you require more information, please contact the Centre Chantal Bérubé Community Youth Centre at 780-929-5155 or by email at youthcentre@town.beaumont.ab.ca
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