Confidence Club Registration
Returning for 2019-2020 with Robyn Aitken & Kim Adriaansen
Helping girls grow, have fun and learn new skills!
- Encouragement and Respect for Self, Others and Environment
- Time Away from Technology
- How to Have Fun Outdoors and More!

~ Running the first Monday of each month
~ First Club night: October 7/19
~ Last Club night: April 6/20
~ 4:00PM - 5:00PM
~ $50 for the year
~ Ages 10 -13
~ 20 Maximum
~ No Confidence Club session held if school is cancelled
Contact us at (204) 834-6623 or rec@townofcarberry.ca

If the Medical Conditions/Allergies/Special Needs and Medications Taken/Required questions do not apply, please answer either "None" or "N/A" to proceed to the next question.
Participant Name *
Your answer
Email *
Your answer
Box Number *
Your answer
Town *
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Postal Code *
Your answer
Birthday *
MM
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DD
/
YYYY
Current Age *
Your answer
Medical Numbers *
Your answer
Medical Conditions/Allergies/Special Needs *
Your answer
Medications Taken/Required *
Your answer
Emergency Contact Name and Phone Number *
Your answer
Parent/Guardian Name(s) *
Your answer
Parent/Guardian Primary Phone Number(s) *
Your answer
How would you like to pay for this class? *
Required
I understand that my registration is not complete until I have submitted payment *
Required
Informed Consent Agreement
I declare having read and understood the above INFORMED CONSENT AGREEMENT in its entirety and hereby consent to participate acknowledging all of the above. Clicking yes to this question shall be considered equivalent to signing the document. *
Required
I authorize the TOWN OF CARBERRY/MUN OF NORTH CYPRESS-LANGFORD RECREATION DEPARTMENT’S CONFIDENCE CLUB PROGRAM to take photographs of my child during the activities to display and otherwise use these photos without charge solely for the purpose of promotional material in connection with the program. *
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