MYAC Membership Application
It is the responsibility of the parent/guardian and/or participant to notify the Program Coordinator of any changes to the following information.
Email address *
First Name *
Your answer
Last Name *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Address *
Your answer
School *
Your answer
Grade *
Your answer
Parent / Guardian Name (s) *
Your answer
OPTIONAL: I identify as a newcomer.
Parent / Guardian (s) Phone Number *
Your answer
Alternate Phone Number
Your answer
Emergency Contact Name & Relationship to Member (different than Parent / Guardian) *
Your answer
Emergency Contact Phone Number *
Your answer
Does this participant have any medical issues / are they currently taking any medication? *
If yes, please specify
Your answer
Does this participant have food or other allergies? *
If yes, please specify
Your answer
Does this participant carry an Epi-Pen? *
Manitoba Medical Number (6 digits) *
Your answer
Manitoba Medical ID Number (9 digits)
Your answer
Picture Release Permission: This release is for all members of Maples Youth Activity Centre. In the course of activities representative of MYAC, participants and staff may take photographs or otherwise record events. These photographs and recordings are sometimes used to promote programming. I give permission to MYAC to photograph and record my child/ward's image and voice. Please advise us if you are willing to have your child/ward’s image and voice used for promotional purposes by MYAC. *
MYAC Rules & Regulations: 1) Be kind and respectful to one another. MYAC has youth of all ages attending our program and what is appropriate for you may not be appropriate for others. 2) All participants will be given a Registration Form which needs to be filled out, signed and returned in order to participate. Those that continue to return without a completed Registration Form may be asked to leave by MYAC Staff. 3) There will be zero tolerance for swearing. MYAC Staff has the right to ask you to leave after a warning if you continue to use foul language. 4) No participants are allowed in the equipment room or any offices unless accompanied by a MYAC Staff member. 5) If something breaks, please let a MYAC Staff member know so we can replace the item. 6) No dunking or hanging on basketball rims. 7) MYAC is not responsible for any lost or stolen items. Please leave valuables at home. 8) No loitering in the hallways or washrooms during MYAC hours. *MYAC staff will use their best judgement to deal with any other issues that may occur. MYAC staff have the authority to ask anyone not following the rules & regulations to leave. In certain circumstances, parents will be informed and participants may be asked to not return to the program for a number of days or weeks depending on the severity of the problem and/or corrective action required.* *
Drop-In Policy: I understand that MYAC operates with an open door policy and is a drop-in centre. During operation hours, members are free to come and go as they choose. MYAC is not responsible for keeping participants on the premises. MYAC is not responsible for you when you leave the facility. I agree to release Maples Youth Activity Centre, its employees, agents and representatives from any and all responsibility or liability whatsoever for any loss, damage or injuries occurring to my child/ward, myself and/or any property of either of us arising from any case whatsoever. Parents/guardians please type your name below once you have read & agree to the above informed consent: *
Your answer
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