Beyond the Box Registration

Student's Name

First Last

Student's Birthdate

Gender

What school does your student go to right now?

Which location would you like to register your youth for?

Elora Centre For The Arts (75 Melville St, Elora)
Fergus BHive (900 Tower St, Fergus)

Was the student born in Canada?

Yes
No

Name of Parent/Guardian

First Last

Family Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family Phone Number

Family Email

Enter Email Confirm Email

This email will be used to communicate with the Parent/Guardian of the student participating in Go Girls Online.

Student's Known Allergies:

(eg. peanuts, food sensitivities, bees, etc.)

Students Medical/Behavioural Concerns:

(eg. ADD, Asthma, Autism Spectrum Disorder, Fetal Alcohol Spectrum Disorder, Learning Disabilities, Diabetes, etc.)

Hidden

Tuesdays 4:30 - 5:30pm

Our next Go Girls! Virtual Edition begins Tuesday April 20, 2021

Is there anything else we should know about your child that will help us serve them to the best of our ability?

Photo Consent (Program Promotion/Awareness Raising)*

Yes
No

Any photographs or video productions taken of children or youth by agency staff at recreational events or match outings, or otherwise authorized by the Executive Director or Board of Directors, may be used by the agency for the purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and web pages, such as the Agency website and social media. Photographs or video productions may also be shared with community and school partners for program promotion. My child’s FIRST name only, general personal circumstances, and general information about their match may be included.

Informed Program Consent*

Yes

I hereby give permission to BIG BROTHERS BIG SISTERS OF CENTRE WELLINGTON to make available their service to my child. It is my understanding that the intention of the Agency is to offer my child an opportunity to participate in a group program lead by a responsible adult, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program. In consideration for this service and other valuable consideration provided to my child by BIG BROTHERS BIG SISTERS OF CENTRE WELLINGTON, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my child. I permit the agency to release any relevant information, including my personal information, to Big Brothers Big Sisters of Canada and their insurers, as may be appropriate in connection with any legal proceeding, inquiry or risk thereof. I understand that the collection of personal information about me or my child will be held in strict confidence and is to be used solely for the purposes of administering the program. I further agree that information about my child may be shared, at the discretion of BIG BROTHERS BIG SISTERS OF CENTRE WELLINGTON, with the group facilitator so that my child’s needs may be best met. I understand that this application is the property of BIG BROTHERS BIG SISTERS OF CENTRE WELLINGTON. I HAVE READ AND UNDERSTAND THIS AGREEMENT. BY CHECKING "YES" TO THIS AGREEMENT, I ACKNOWLEDGE THAT: I am the parent/guardian of the child mentioned above, and I hereby request Big Brothers Big Sisters service for my child. I give my child permission to participate in one or more group programs offered by BIG BROTHERS BIG SISTERS OF CENTRE WELLINGTON. I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for my child.

Beyond The Box! Safety Guidelines: Parent Consent*

I have read and agree to the Beyond the Box! Safety Guidelines form below

Beyond The Box Registration