This personal information is being collected under the authority of the Freedom of Information and Protection of Privacy (FIOP) Act, Section 33(c). This information will be used in the administration of this program. If you have any questions regarding the collection and use of this information, please contact the City of Revelstoke admin@revelstoke.ca 

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YOUTH - GENERAL ACTIVITY

Emergency Information and Permissions Form


Review City of Revelstoke Privacy Policy

I have read this Consent Form and understand and accept its terms. 

Parent/Guardian initials:

Date: July 20, 2024

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Child’s Care Card #: *

Child's Doctor:

Child's Civic Address:

City:

Postal Code:
I grant permission that PRC staff may authorize necessary medical treatment, in an emergency, by a licensed physician, for my child without personal liability, if I am unable to be contacted in a timely manner. This authorization shall be valid for the full duration of the students enrollment in PRC programs.*

Other notes we should be aware of: (i.e. allergies, medical conditions etc.)
Please indicate your child’s swimming ability:*

PICK-UP PERMISSION:

I understand that it is my responsibility to pick up or make suitable arrangements for the pick-up of the child, immediately on completion of the Activity, and to communicate clearly and effectively to community centre staff, prior to commencement of the Activity, and any special instructions regarding the pick-up of the Child on completion of the activity. Emergency and alternate contacts will be on the pick-up list for the child. 

My child is allowed to sign himself/herself out at the end of the day:*

ADDITIONAL RELEASE PERMISSIONS

MINOR (CHILD) PHOTO RELEASE PERMISSION

This permission form allows the use of photo likenesses of your child to be used in community publications. I give my informed consent that photos of my child may be published.*

SUNSCREEN APPLICATION PERMISSION 

This permission form allows the application of sunscreen to my child when in outdoor programming. I give permission for sunscreen to be applied to my child.*

COMMUNICATION PERMISSION 

I, give permission to the City of Revelstoke Parks, Recreation & Culture to consult with the local schools regarding my child's care. This communication between organizations will only be required on an information need to know basis and occurs in accordance with the FIOP (Freedom of Information and Protection of Privacy Act). Confidentiality of this information is respected at all times.*

EXCURSION PERMISSION 

I give my child permission to walk to, and participate in all activities, field trips, workshops, and off-site excursions in the general area surrounding the program location while accompanied by a minimum of 1 instructor.*
First Participant's Signature*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact Information

Parent/Guardian's Name *

Parent/Guardian's Phone: *

Additional Parent/Guardian’s Name:

Additional Parent/Guardian’s Phone:

Emergency Contacts

We will always call a parent/ guardian first in an emergency. If the parent/ guardian is unreachable, who can we contact? 

(Please provide two alternative contacts, friends or family etc) 


Contact's Name *

Contact's Phone *

OR


Contact's Name

Contact's Phone
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Child’s Care Card #: *

Child's Doctor:

Child's Civic Address:

City:

Postal Code:
I grant permission that PRC staff may authorize necessary medical treatment, in an emergency, by a licensed physician, for my child without personal liability, if I am unable to be contacted in a timely manner. This authorization shall be valid for the full duration of the students enrollment in PRC programs.*

Other notes we should be aware of: (i.e. allergies, medical conditions etc.)
Please indicate your child’s swimming ability:*

PICK-UP PERMISSION:

I understand that it is my responsibility to pick up or make suitable arrangements for the pick-up of the child, immediately on completion of the Activity, and to communicate clearly and effectively to community centre staff, prior to commencement of the Activity, and any special instructions regarding the pick-up of the Child on completion of the activity. Emergency and alternate contacts will be on the pick-up list for the child. 

My child is allowed to sign himself/herself out at the end of the day:*

ADDITIONAL RELEASE PERMISSIONS

MINOR (CHILD) PHOTO RELEASE PERMISSION

This permission form allows the use of photo likenesses of your child to be used in community publications. I give my informed consent that photos of my child may be published.*

SUNSCREEN APPLICATION PERMISSION 

This permission form allows the application of sunscreen to my child when in outdoor programming. I give permission for sunscreen to be applied to my child.*

COMMUNICATION PERMISSION 

I, give permission to the City of Revelstoke Parks, Recreation & Culture to consult with the local schools regarding my child's care. This communication between organizations will only be required on an information need to know basis and occurs in accordance with the FIOP (Freedom of Information and Protection of Privacy Act). Confidentiality of this information is respected at all times.*

EXCURSION PERMISSION 

I give my child permission to walk to, and participate in all activities, field trips, workshops, and off-site excursions in the general area surrounding the program location while accompanied by a minimum of 1 instructor.*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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