Child and Youth Registration

CHILD & YOUTH REGISTRATION FORM

PERSONAL INFORMATION

First Name

Birthday

Last Name

Age

Parent/Guardian Name

Parent/ Guardian Email

Primary Phone Number

Secondary Phone Number

Address

EMERGENCY CONTACT

Emergency Contact Name

Emergency Contact Number

Relationship to Child

Child's Health Card #

Allergies or Dietary Restrictions

Other

PHOTO / VIDEO RELEASE

Rose City Kids may have an opportunity to receive exposure from various media outlets such as TV or newspaper. As well, RCK may produce publications of its own to raise funds and awareness for the programs we are able to provide for the children. It’s important for us to ensure the privacy of each of the children in our care, therefore we require a signature from a parent or guardian to grant permission for your child’s photo to be taken.

Your Signature

Date

YOUTH (GRADES 7-12) ONLY

In the context of Tuesday and Thursday Night Youth Nights for students in grade 7 through to grade 12 will be given the option of being signed out by a parent or guardian or they can walk home. To ensure the safety of each student, we want to verify that your student does or does not have permission to walk home in the evening without being signed out by an adult. Please check off yes or no below and sign and date. Thank you.

Yes, I give permission for my child/student to walk home

No, I do not give permission for my child/student to walk home

Your Signature

Date

CHILD & YOUTH REGISTRATION FORM

Thanks for submitting!