Registration Form Taekwondo and yoga for children, teens, parents and families. Adapted for all abilities and special needs. Please check the class section you are registering for.
Class A - Mini Masters Ages Eight & Under 5:15pm - 6:15pm
Class B - Intermediate
Class C - Advanced
Ages Twelve & Under 6:20pm - 7:20pm
All Ages 7:25pm - 8:25pm
Participant’s Name ___________________________________ Date of Birth _____ | _____ | _____ Alberta Healthcare #______________________________ Participant’s Name ___________________________________ Date of Birth _____ | _____ | _____ Alberta Healthcare #______________________________ Participant’s Name ___________________________________ Date of Birth _____ | _____ | _____ Alberta Healthcare #______________________________ Parent/Guardian Name _______________________________________ Home Phone ______________________________ Work Phone ______________________________ Cell Phone ______________________________ Email ______________________________ Emergency Contact ______________________________ Phone ______________________________
Physician’s Name ______________________________ Phone ______________________________ List any known allergies ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ List any medication(s) that your child is currently taking ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Please list any activity limitations your child may have ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Please list all persons authorized to pick up your child ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________
I give consent to Qi Creative staff and volunteers to arrange for any medical treatment and/or ambulance should it be required in the event of an illness or injury. I understand that payment for these services is my responsibility. Yes No
Parent / Guardian Signature _____________________________________
I give permission to Qi Creative staff and volunteers to request/release information concerning my child’s communication and learning abilities from/to any relevant agencies. Yes No
Parent / Guardian Signature _____________________________________
I authorize Qi Creative staff to contact, discuss and obtain my child’s FSCD service agreement information from FSCD staff if applicable. Yes No
Parent / Guardian Signature _____________________________________
I give permission to Qi Creative staff and volunteers to record video of the group sessions in order to collect and analyse data. I understand the recordings may be used for workshops, presentations and/or commercial use. Yes No
Parent / Guardian Signature _____________________________________
I, _________________________________ , understand the above in accordance with the Freedom of Information and Protection of Privacy Act dated this ______ day of ____________ , 20 ____ .
Parent / Guardian Signature _____________________________________
Please Return This Form as Soon as Possible. Registration is Based on Availability.
QiCreative.com| 780.860.2222 | PaulaDemay@QiCreative.com Mailing Address -9801 93a Avenue, Edmonton, AB T6E 2W4 Qi Creative Do Jang 9410 - 118 Avenue