New Waterford Registration

Please use our registration form below to register your child for one of our activities.

Participant's Name *

First

Last

Age *

Year of Birth *

Month of Birth *

Day of Birth *

Name of Parent/Guardian *

Contact Number *

Email *

Address *

MEDICAL CONSENT:

Information received is confidential and is being gathered for the purposes of serving the participant. Any medical information collected here serves to authorize Undercurrent and its staff/volunteers to obtain medical assistance in emergencies. In the case of an incident, please consent to the following information:

Child's Health Card Number *

Does your child have any allergies, physical, emotional, mental, behavioural concerns and/or limitations that our staff should be aware of? *

If YES, please explain:

This form is used for all programs we run. Please list the programs you are interested in:

Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Lighthouse of Cape Breton / Undercurrent and its staff/volunteers are hereby released from any liability. In the event that your child requires emergency treatment, you or your designated emergency contact will be notified immediately.

I am aware that while participating in a recreation activity or program arranged by Lighthouse/Undercurrent certain risks/dangers may be present, including but not limited to those generally associated with certain activities, such as hazards, traveling public highways, accidents, illness, and/or forces of nature.

I agree to release Lighthouse/Undercurrent and to indemnify and defend Lighthouse/Undercurrent and hold it harmless from and against any and all claims, suits, damages, liabilities and expenses, including attorney’s fees and the Church’s cost of defense, in connection with loss of life, personal or bodily injury and/or damage to or loss of property that arises from the participation in Lighthouse/Undercurrent, except to the extent that such loss, injury or damage is occasioned by the negligent act or omission of Lighthouse/Undercurrent, its officers, agents or employees and no negligence on the part of the Participant.

As a participant, parent or guardian I understand the following: That there are inherent dangers in any recreational activity or program. That I must be aware of the hazards associated with each activity, such as use of equipment, slips and falls, personal level of fitness, training, and various athletic injuries related to this activity. I must read and understand all written material which has been provided by Lighthouse Community Church / Undercurrent; the rules and regulations for each activity, as explained in any written materials and/or explained by staff. These include that Undercurrent has a zero tolerance policy for swearing, fighting, bullying, alcohol, and illegal drugs. That the possible consequences of participating in these activities include the possibility of serious injury and/or dismissal.

I have read, understood, and agree with the above information as it applies to Undercurrent Youth Centre and have effectively stated the truth to the best of my knowledge.

Parent/Guardian's Name or Participant if over 18 years of age: *

First

Last

By entering your name above, you understand that this acts as your signature and permission for your child (or you, if you're over 18) to attend this program.

Cost:

All our programs are Pay What You Can. Thanks for helping us keep these programs going.

Current Month *

Today's Date *

Current Year *

PHOTO RELEASE — Are you okay with your child being in any photos taken for promotional purposes, such as, but not limited to Lighthouse/Undercurrent website, Facebook group, video, newsletter, and/or additional promotional material? Please choose below: *

Yes—you can use photos of my child
No—please do not use photos of my child