Thank You – SibShop – Empower Simcoe

Participant Information

Name

First

Last

Birthdate

Age

Gender

School participants attends:

Grade:

Do you have another participant joining this SibShop?

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Parent/Guardian Information

Parent/Guardian Name(s)

Parent/Guardian Email

Home Phone

Cell Phone

Work Phone

How did you hear about our SibShop?

Number of siblings with special needs:

1
2
3 or more

Age of sibling:

Gender:

Description of diagnosis:

Other siblings in the home (names and ages):

What do you hope this participant will gain from our Sibshop? Are there any particular topics you would like to address?

Does this participant have any food allergies, food sensitivities, or dietary restrictions? Please list.

Please provide any further information that you feel would make Sibshops a more enjoyable and educational experience.?

PHOTOGRAPHY/MEDIA CONSENT AND RELEASE

Empower Simcoe sometimes asks people to let us use their photo, video or audio to promote Empower Simcoe’s work or
tell others what we do.

I understand that a photo, video or social media posting may appear in public promotional material for many years.
Empower Simcoe may, at any time, reproduce, publish and/or republish the video, photograph(s) or audio for
any communication, advertising and/or promotional purposes, including the posting of the video or any portion thereof
on the agency’s websites.

This consent will remain valid for one year from the date signed.

Authorizing person(s) may cancel or change the above authorization in writing at any time prior to the expiry date, unless
action has already been taken on the basis of the authorization.

I hereby give my/our permission and consent to Empower Simcoe to collect and use Photography and/or Video of this participant to promote and advertise the programs & services of Empower Simcoe.

I hereby give my/our permission and consent to Empower Simcoe to collect and use Photography and/or Video of this participant to promote and advertise the programs & services of Empower Simcoe, including:

WAIVER AND CONDITIONS OF ENROLMENT

The parent/guardian(s) of the above-named participant, release Empower Simcoe, its Staff and Volunteers from any loss, personal injury, accident, misfortune or damage to the above-named or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named participant.
In case of medical emergency, the parent/guardian(s) of the above-named participant understands that every effort will be made to contact them. In the event that the parent/guardian cannot be reached, I/we give permission to the Empower Simcoe Staff and the attending doctor to secure medical treatment for and/or hospitalize the above-named participant.

I have read and hereby agree with the waivers and conditions of enrolment.

Name of person completing form:

Relationship to participant:

Signature

Clear Signature

Thank You – SibShop

Participant Information

Parent/Guardian Information

PHOTOGRAPHY/MEDIA CONSENT AND RELEASE

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