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CITYKIDZ REGISTRATION FORM

2024 Registration Form

Please be advised that eligibility is based on where you live, we will send you an email to confirm. 

Dear Parent/Guardian, 

At CityKidz, we prioritize the safety and security of all children participating in our programs. To ensure their well-being, we collect the following information about your child(ren), which will be kept confidential and only accessed by CityKidz staff in the event of a health or safety concern. If you have any questions or would like to speak to a staff member, please do not hesitate to call us at 905-544-3996 ext. 229.

October 4, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Parent/Guardian Information

How did you hear about CityKidz?

Primary Parent/ Guardian Full Name: *

Relationship to Child: *

Address: *

Phone Number:

Email: *

Secondary Parent/ Guardian Full Name:

Relationship to Child:

Address:

Phone Number: *

Email: *
To ensure the safety during pick ups and drop offs of your child please provide the following information:
Primary Parent/Guardian has sole legal custody of child
Secondary Parent/Guardian has sole legal custody of child
Primary & Secondary Parent/Guardian both have legal custody of child

Other additional information we may need to know regarding custody:
Primary Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
SIBLING INFORMATION

Name of Siblings:

Birthdate of Sibling (DD/MM/YYYY):
EMERGENCY CONTACT INFORMATION (Must be different from primary and secondary parent/guardian)

First Name:

Last Name:

Relationship to child:

Address:

Primary Phone #:

Secondary Phone #:
CONSENT
I give CityKidz permission to transport my child to and from the CityKidz program on a CityKidz bus and/or by a CityKidz Staff/Volunteer. *
Yes
No
I give consent for CityKidz to take photographs and/or video of my child and give permission to CityKidz to use these images in promotional publications, including, but not limited to, newsletters, websites, documents, brochures, newspapers and/or television. *
Yes
No
I give CityKidz permission to publish my child’s full name in connection with any photograph/video that they may appear in.*
Yes
No

I hereby authorize CityKidz and/or its representatives to collect, use and appropriately distribute the personal information contained in this Permission Form. I am aware that CityKidz has a Privacy Policy which is available online at http://citykidz.ca/privacy. This document shall be full and sufficient authority for the collection, use and distribution of personal information in accordance with CityKidz’ Privacy Policy.

I understand that CityKidz cannot be held responsible for any injuries or expenses, costs and/or claims in connection with any injuries sustained which were not directly caused by their failure to take due care. I also understand that my child’s participation in CityKidz activities is conditional upon my signing this waiver and releasing CityKidz and its staff and volunteers. I hereby agree to release CityKidz, its staff and volunteers from any and all claims for liability arising from my child’s participation in the CityKidz program. In the event that my child requires medical attention, until such time as I may be contacted, I hereby authorize any CityKidz staff to seek medical treatment and medical personnel in charge of my child to administer such medical or surgical treatment or carry out such procedure as may be deemed necessary or advisable in the diagnosis or treatment of my child. I also assume the responsibility for the payment of any such treatment.

 


I have read and understood the above, and I am aware that my child, ________________________, will be participating in the CityKidz program. I hereby give my full permission for him/her to participate. *

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.
Primary Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Primary Parent or Guardian's Date of Birth*
Primary Parent or Guardian's Information

Home Address:

Current Age:

Gender:

School:
Current Grade:*
Languages spoken at home:
English
French
Spanish
Arabic

Other:

Child Health Information


Health Card Information (Optional):

Food Restrictions:

Medical or Physical Concerns (e.g., Asthma, epilepsy, sight, hearing, etc.):

Behavioural, Mental or Emotional Concerns (e.g., ADHD, anxiety, autism, etc.):

Best Response to concerns:

Other important information:
Does your child have an Epi Pen?*
No
Yes
Does your child have an Inhaler? *
No
Yes
Can they self-administer their Inhaler?*
No
Yes

Allergy Information

Please list any allergies your child may have, including reactions and best response:


Allergy (e.g., Peanuts, grass)

Reactions (e.g., Hives, can’t breathe)

Best Response? (e.g., Benadryl, Epi Pen, 911)
Primary 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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