Winter 2016/17 Mini-Teens Registration Registration may be made at the Chantal Berube Youth Centre (5202 50ST), in person Tuesday-Thursday 3:30pm-8:00pm, or Friday-Saturday 5pm-10pm. Drop-in registrations can be made on the day of Mini-Teens but space is limited. A snack will be provided and the cost of Mini-Teens is $5.00. Maximum 30 participants
Name of Participant ________________________________________ Name of Parent/Guardian: ________________________________________ Additional Information: (please be as specific as possible)
Birth Date of Participant: ________________________________________________
(must be between the ages of 6-11 to participate)
Allergies:______________________________ Any medical considerations? _____________________________________
Address _________________________________________________
Telephone number of Parent/Guardian
_____________________________________ Emergency Contact Name/#: _____________________________________________
Mini Teens Registration Dates Saturday, December 17, 2016
1-4pm
Saturday, January 21, 2017
1-4pm
Saturday, February 11, 2017
1-4pm
Please indicate which day(s) Cost ($5/Mini-Teens event) you are registering for Includes snack
Town of Beaumont 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 ( r en ) 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 Participants Parent/Guardian
_ _ _ _ _ _ _ _ _ _____ _ _ _ _ _ _ _ _ _ _ _ _ _ Witness
_ _ ___________ _ _ _ _ Date
For more information contact the Chantal Berube Youth Centre at (780)929-5155. Information and Registration Forms are available at the Chantal Berube Youth Centre or online at www.beaumont.ab.ca/youth 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) 929-8782