______________________________________ CBYC Corn Maze Trip Registration Form (ages 12-17) October 14, 2016 6-10pm Registration Procedures: Telephone registrations will not be accepted. Registration and payment is due two days prior to event unless otherwise specified. Cash or cheque payments can be made. Make cheques payable to Town of Beaumont. _______________________________________________________________________________________________________
Surname: _______________________________ Parent/Guardian:________________________________ Address: ______________________________________________________ Postal Code:_____________ Telephone Numbers: (Home) _______________________ (Work/Daytime)_________________________ Email Address:_________________________________________________________________________ Participant Name
Age
Program
Fee
Corn Maze Trip October 14 6-10pm $15 Includes bus, admission and a snack (bus leaves from the CBYC at 6pm) Additional Information:(please be as specific as possible) Allergies:_____________________________________________________________________________________ Any medical considerations?_____________________________________________________________________ Emergency Contact Name/#:____________________________________________________________________ Waiver for Activities This Waiver for Activities form must be completed before attending any programs. Please read carefully. I give my permission for my child(ren) ____________________ to participate in _____________________ on (date) __________________. I understand the nature of the activity, the limited supervision provided and that there are inherent risks associated with this activity and that my child(ren) could sustain personal injury through participation in this activity and I am hereby accepting to take that risk on behalf of my child(ren). I hereby agree to save harmless and indemnify the Town of Beaumont, it’s organizers, agents or employees against claims, expenses and demands in respect to injury or death arising out of myself or my child(ren) taking part in this activity, but limited to taking part in this activity. _____________________________________ _____________________________ Signature of Participant’s Parent/Guardian Witness
_______________________ Date
Please note; The personal information contained on this form is being collected under the authority of the Municipal Government and FOIP Acts, and will be used as required by Town staff for registering in and promoting of recreation programs, accounting purposes, medical and emergency information. The collection of this information is protected by the privacy provisions of the FOIP Act. Photographs may be used for advertising purposes. If you have any questions or concerns, please contact the FOIP coordinator at the Town of Beaumont (780) 9298782
For more information please contact Adrienne King (CBYC Program Coordinator) by phone at (780) 929-5155 or by email at adrienne.king@beaumont.ab.ca
Chantal Berube Youth Centre 5202 50 Street Beaumont AB