Online Youth Registration Form
Registration Information, Waiver and Media Release for the YAK Youth Centre
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Email *
Is your child able to sign themselves out of the Centre? *
Required
Today's Date *
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Youth Information
Name of Youth (First and Last) *
 Preferred Pronoun(s)
 *
Date of Birth *
MM
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DD
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YYYY
Grade
 *
Youth Contact Information (indicate home/cell phone number, email, etc...) *
Parent or Guardian Information
Name of Parent or Guardian *
Relationship to Youth
 *
Parent or Guardian Contact Information (indicate home/cell phone number, email, etc...) *
Mailing Address
 *
Town or Township
 *
Alternative Emergency Contact
Name of Emergency Contact
 *
Relationship to Youth
 *
Emergency Contact Information (indicate home/cell phone number, email, etc...)
 *
To Be Completed By Parent/Guardian
Please check any of the following characteristics that describe your child/ward
 *
Required
Please tell us about your child’s interests (tick all that apply)
 *
Required
Relationships
How does your child/ward get along with other youth?
 *
Are there any specific challenges we should be aware of?
 *
Health and Allergy Information
Does your child have any allergies, mental health or physical health conditions that we should know about? *
Does your child take any medication? (If yes, please list them) *
Waiver and Media Release
Liability Waiver
YAK Youth Services is proud to offer youth a variety of opportunities to participate in involving leisure, recreation, entertainment and educational activates. Activities may include, but are not limited to, after-school drop-in programs, youth fitness programs, music programs, social, emotional and mental health learning, kitchen programs, homework help and workforce readiness training. Youth are supervised during all activities by qualified youth workers who promote the safety and enjoyment of all participants.

There is some element of risk in any activity. By providing consent to participate in YAK Youth Services activities, the parent/guardian and youth assumes all risks associated with the activity and releases YAK Youth Services, its respective officers, staff and volunteers from liability in claims of injury or property loss/damage as a result of the youth’s involvement in the activities.
Please Indicate Below for Consent *
Required
Consent for Medical Treatment
It is our practice to notify a parent/guardian when a youth is ill or needs medical attention. In the case of a significant medical event or emergency, YAK staff will get immediate help for the youth, whether or not parents/guardians have been notified. In such circumstance staff may take the youth to the nearest emergency centre or, when appropriate, call first responders for help. If an ambulance is used in response to the emergency or event, associated costs may be incurred by the parent/guardian.
Please Indicate Below for Consent *
Required
Media Release
I give YAK Youth Services the right to use photographs, videos or recordings of myself or my child/dependent (named below) for the purpose of promoting YAK through printed materials, media releases and social media. I understand that my identity of the identity of my child/dependent may be revealed.

I agree that YAK may use this material in print or electronic form, publicly or privately. I release YAK from any claims and demands in connection with the use of this material for the purposes mentioned above. I understand that I will not receive and financial or other remuneration for allowing YAK to use this material.

I confirm that I have read this agreement, fully understand its contents, and am agreeing to this voluntarily.
*
Please list any events or types of activities your youth is NOT permitted to attend/participate in:
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