Thank You – Create and Inspire Art

Thank you for registering to Create and Inspire Art! Don’t forget to complete the Participant Information Form below.

If you have any questions or concerns please contact us at ffs-35w@empowersimcoe.ca.

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Participant Information

Please fill out all form fields unless previously submitted.

Name *

First

Last

Birthdate *

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 this course?

Emergency Contact

Separate Household – to be contacted in case parent/guardian cannot be reached.

Name *

First

Last

Relation to Person Supported

Home Phone

Cell Phone

Work Phone

REQUIREMENTS FOR SUPPORT WORKERS – PLEASE READ CAREFULLY

Empower Simcoe attempts to ensure that all participants in the program are provided with supports appropriate to meet their needs.

This course provides a minimum 1:4 staffing ratio. We recognize that some people may require 1:1 support – all 1:1 support workers must be arranged by the family.

Will this participant be attending with a 1:1 Support Worker? *

In order for a family-employed Support Worker to accompany this person, that Support Worker must either:

Submit a Criminal Reference Check with Vulnerable Sector Screening that has been completed within the last 90 days from the time of submission, OR
Must have completed the CHAP (Community Helper for Active Participation) registration process through supportyourway.ca/respiteservices.com.

If you are hiring a CHAP (through supportyourway.ca/respiteservices.com), please notify a Youth Program Leader of the Support Worker’s name and phone number
If you would like to hire a CHAP, please contact Carolyn Harris, Respite Coordinator with Empower Simcoe, at 705-726-9082 extension 2259 or at charris@empowersimcoe.ca
If you are hiring a Support Worker who is not a CHAP, please have the Support Worker submit a Criminal Record Check with Vulnerable Sector Screening to the Youth Engagement Facilitator (via email, fax, mail or hardcopy)

Fee For Service
ffs-35w@empowersimcoe.ca

Please sign below to confirm that you have read, acknowledged and understand the Support Worker requirements.

Clear Signature

Behavioural & Health Considerations

In this section of the registration form we will ask questions about this participant and how we can best support them. Please complete this section in detail and include any necessary information you see as important to best support this person. Our goal is to make everyone’s experience the most rewarding. A Community Participation Support Worker may connect with you to learn more about this person if the amount of detail is insufficient or clarification is required.

Please select any of the following behaviours that may be exhibited by this participant:

Pacing
Swearing
Yelling
Clapping/Tapping
Leaving the Group
Quiet/Withdrawn
Pinching
Biting
Hitting
Scratching

Other behaviours:

Health Considerations

Does this participant have any of the following health conditions? *

Anaphylactic Allergies (especially food, plants or bees)
Seizures
Persistent Cough
Asthma
Headaches
Depression/Anxiety
None of the above

Other health conditions not listed above:

How are these health concerns normally managed?

How does this participant communicate with others? *

Speech
Sign Language
Gestures
iPod/iPad
Pictures
Augmentative Communication Device

Other methods of communication:

Does this participant require or use a wheelchair or other mobility aid? *

Yes
No
Occasionally

Please share any further information that you think would be valuable for us to know that has not yet been stated

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: *

Agency Publications
Agency internal websites
Agency external websites
Broadcast TV / Radio
Social Media
Media Promotion
Public Education
Trainings (Staff/Volunteer)
None of the above

WAIVER AND CONDITIONS OF ENROLMENT

The parent/guardian(s) or authorized support staff of the above-named participant, release Empower Simcoe, its Community Participation Support Workers, Supervisor, 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.
Empower Simcoe reserves the right to dismiss or not accept a participant who, in our opinion presents a hazard to the safety and rights of others, or who appears to have rejected the reasonable controls of the program. Failure to disclose any medical, emotional or behavioural conditions on this form could results in the participant being excused from this program without refund.
If it is determined that a participant requires a 1:1 support worker, the parent/guardian or authorized support staff is responsible for arranging this support, a participant may not be invited back to our program until a suitable support is in place.
REFUND POLICY: Cancellation more than two weeks prior to the start of the course – full refund less $50.00 administration fee. Withdrawal during the course on physician’s order – one half of fee for unexpired term will be refunded. No refund will be made for dismissals due to disciplinary action, late arrivals or early departures.

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

Name of person completing form: *

Relationship to participant: *

Signature