Northumberland Promise After School Program Registration (Grades SK to 16 years)

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GAMES, CRAFTS, SNACKS - LIFE LESSON STORIES FROM THE BIBLE

Thursdays 4:00-5:30pm starting October 10, 2024

SALVATION ARMY CHURCH | 59 BALLANTINE STREET, COBOURG

Contact: info@northumberlandpromise.com

Child's Name *

Date of Birth (month/day/year) *

YYYY

Grade
*

Parents/Guardians Names *

Child's Address *

Email *

Phone *

Emergency Contact and Phone Number (if different from above)

Allergies - Please list any allergies your child may have. If none, please answer "none". *

Does your child carry a puffer or epi-pen? If so, please provide instructions in writing regarding its' use. Please note that Northumberland Promise team will follow your instructions regarding administration of these two forms of medication. Staff are not permitted to administer any other forms of medication for your child.

Does your child have any physical, emotional, or behavioural concerns or limitations that we should be aware of? Please note that the dignity of each child will be respected and supported at all times.

Medical Permission - I, the parent or guardian named above, authorize a Northumberland Promise volunteer to sign a consent for medical treatment and to authorize a physician or hospital to provide medical assessment, treatment, or procedures for the participant named above in the event that I cannot be reached. *

I GIVE permission

I DO NOT GIVE permission

Required

I understand Northumberland Promise occasionally captures photographs and video footage during our events and activities for use in brochures, promotional materials, our website, newsletters, and social media. If you prefer not to have your image used for these purposes, please indicate by checking the box below. *

I give permission for photographs and/or videos to be taken of my child.

I do not give permission for photographs and/or videos to be taken of my child.

Required

By giving my name below, I agree to indemnify and hold blameless, Northumberland Promise, including all volunteers, Staff, and Board of Elders from any loss, damage or injury suffered by my child as a result of being part of the after school program, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in events of Northumberland Promise.
*

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