Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 2Participant InformationName *FirstLastBirthdate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeGenderMaleFemalePrefer not to discloseSchool participants attends: *Grade: *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeParent/Guardian InformationParent/Guardian Name(s) *Parent/Guardian Email *Home PhoneCell PhoneWork PhoneHow did you hear about our SibShop?Number of siblings with special needs:123 or moreAge of sibling:Gender:MaleFemalePrefer not to discloseDescription of diagnosis:Age of sibling:Gender:MaleFemalePrefer not to discloseDescription of diagnosis:Age of sibling:Gender:MaleFemalePrefer not to discloseDescription of diagnosis:Other siblings in the home (names and ages):What do you hope your child 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.? NextPHOTOGRAPHY/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: *Agency PublicationsAgency internal websitesAgency external websitesBroadcast TV / RadioSocial MediaMedia PromotionPublic EducationTrainings (Staff/Volunteer)None of the aboveWAIVER 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 Submit
