Online Participant Permission Form Winter 2020/21
This form is to be filled out by Participants Legal Guardian in order to take part in our Online Programs
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Email *
Participants Name *
Parent/Legal Guardian's Name and Phone Number if Participant is a minor (ages 4-17)
Has you or your child been a registered participant with Silverheights Neighbourhood Association (SNA) in the last year? *
Required
Which Online Program(s) are your interested in signing up for? *
Required
1. Authorization and RELEASE: I, in my personal capacity and on behalf of the participant, do hereby RELEASE FROM ALL LIABILITY Silverheights Neighbourhood Association, its Directors, volunteers, employees, agent and representatives (hereinafter Releasee) for any injuries, illnesses, or other mishap that may be incurred by the participant while attending a registered, drop in or online program or event, except where damage or injury is caused by the gross negligence of the Releasee. In the event the participant should be injured or become ill, I authorize any medical treatment that may be required and will assume full financial responsibility for the said treatment. At no time is the Releasee liable for the action/inaction of any support worker supplied by and/or for the participant. 2. Personal Information collected on this form is obtained incompliance with the Personal Health Information Protection Act (PHIPA) and will used only for the purpose of the SNA. Questions about the collection of personal information should be directed to the SNA Health Information Custodian by calling 519-249-1200. 3. I understand that this form shall be completed no less than each calendar year. 4. I, the Participants Legal Guardian, agree not to share links and meeting I.D. information with outside parties who are not registered with Silverheights Neighbourhood Association and am aware of the risks and dangers associated in sharing information. I acknowledge and fully understand, appreciate and accept the inherent risks associated with my child’s participation in virtual and online activities provided by Silverheights Neighbourhood Association BY SIGNING THIS RELEASE YOU ARE RELEASING YOUR LEGAL RIGHTS AGAINST SNA. *
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