Teen Ranger Registration Form
Please complete one form per participant.
Youth's Full Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian's Full Name
Your answer
Email Address
Your answer
Street Address
Your answer
City
Your answer
Postal Code
Your answer
Preferred Phone Number
Your answer
Alternate Parent or Guardian Phone Number (1)
Your answer
Alternate Parent or Guardian Phone Number (2)
Your answer
Name of Alternate Contact
Your answer
Alternate Contact Phone Number
Your answer
T-Shirt Size
All t-shirts are in adult sizes.
Required
Will your child be taking the bus from Devonshire Mall?
The bus will leave at 8:00 am sharp. Please arrive early. The bus returns for 4:00 pm.
Medical Information
OHIP Number
Your answer
Physician's Name:
Your answer
Physician's Phone Number:
Your answer
Food Allergies
If none, please write "None"
Your answer
Drug Allergies
If none, please write "None"
Your answer
Will your child be taking any medications during the Teen Ranger program? (For emergency information only. Please note that ERCA staff cannot administer medications)
Is so, please list the medication, dosage, and time(s). If none, please write "None"
Your answer
Is there anything else that the Teen Ranger staff should be aware of?
Your answer
Date of most recent tetanus booster :
Please note that this information is helpful in the event of an emergency but that this program does not require participants to supply information related to immunizations.
Your answer
Medical Consent
In the case of a medical emergency, I understand that every effort will be made to reach us for instruction. If, in the judgement of a medical professional, delay in reaching us might jeopardize the child's well-being, we hereby authorize the Teen Ranger staff to (1) release a copy of this health record to a medical doctor and (2) secure whatever medical treatment is deemed necessary, including the administration of anesthetic and surgery.

We further hereby authorize any legally qualified physician/surgeon/hospitals to perform and or furnish emergency medical treatment, surgery, medicine, equipment and services as, in their opinion, may be required.

We hereby release the Essex Region Conservation Authority and its staff from any and all liabilities of any kind and nature arising out of or in connection with the placing of our child in the care of physician/surgeon/hospital, and we hereby agree to pay the reasonable costs of such treatment surgery, medicine, equipment and services so provided that may not be covered by insurance.

Consent
Required
Essex Region Conservation Authority Photo/Video Model Consent

I CONSENT to the use of my child/ward's image for the purpose of promoting Essex region Conservation Authority (ERCA) or the Essex Region Conservation Foundation (ERCF). This included a photograph, digital image or video image. Images may be used online, in leaflets, brochures, flyers, posters, advertisements, e-newsletters, and any other promotional material.

I agree that the photograph of digital image or video image is and shall continue to be the property of the ERCA.

I understand and agree that I will not be compensated in any way for the use of my child/ward's likeness by ERCA or ERCF. I also understand that I am free from any responsibility incurred in the reproduction of images of my likeness by the ERCA or by the ERCF.

Consent
Required
Final Consent
I hereby grant my child/ward permission to participant in all organized activities (as outlined in the accompanying email) for the duration of the Teen Ranger program.
Consent
Required
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