Youth Program Registration Form - Westbank First Nation

Feedback Forms

Child Information:

* Last Name:

* First Name:

* Date of Birth:

Open the calendar popup.

Cell Phone:

Gender: Male
Female
Other
Prefer not to disclose

Program Name(s):

Parent/Guardian Information:

* Last Name:

* First Name:

* Address:

* City:

* Country:

* Province:

* Postal Code:

* Home/Cell Phone Number:

Work Phone Number:

* Email Address:

Social Worker Name (If Applicable):

Social Worker Phone Number:

Medical Information:

* Medical Number:

* Family Doctor:

* Family Doctor Phone Number:

Does your child have any mental, emotional or behavioral limitations that staff should be aware of?

Please list any medications your child takes as well as dosage and times.

If WFN staff are required to administer medication to your child, please specify:

Medical Alert Information:

Health Record:

* My child's immunization record is currently:

Please list any allergies your child has:

Please list any sensitivities your child has (include dietary):

Please list any other health concerns:

Please list any vision, hearing or speech concerns your child has?

Please list any learning or physical concerns your child has?

Please list any special instructions about food likes & dislikes, favorite things ect.

If there is a custody agreement or restraining order in place, please provide copies. Clear

School & Cultural Information:

* Name of School:

* Grade:

* Is your child (check all that apply):

What Nation/Band is your child from?

Emergency Contacts:

* Name:

* Relationship:

* Phone Number

* Pick-up Authorization:

* Name:

* Relationship:

* Phone Number:

* Pick-up Authorization:

Permission:

* Accident / Suspicious Activity:

I realize that the caregiver must report any accidents or a suspicious events. I have read and agree to the above information and will notify the caregiver if there are any changes.

* Medical Emergencies:

In the event of an emergency, I authorize the Westbank First Nation Youth Center to seek emergency medical attention for my child, including but not restricted to calling for ambulance service, contacting the above mentioned doctor, or taking the child to the local hospital emergency room.

* Photographs may be taken of your child(ren) during program hours. Westbank First Nation would like to use these photographs in reports, presentations, fundraising and promotion. Do you consent to this?

* Video Surveillance.

WFN has a duty to ensure the personal safety of WFN's Youth Program employees and participants and to safeguard Youth Program facilities. WFN may therefore conduct video surveillance of Youth Program facilities at any time, excepting private areas of restrooms, showers, and dressing rooms. In acknowledgment and understanding of the foregoing, I hereby give my consent to such video surveillance.