Order Received – Youth Program

Thank you for registering to our Youth Program! Please take a moment to complete the Participant Information Form below if you haven’t already submitted this form for the 2024-25 school year.

If you have any questions or concerns please contact us at youth@empowersimcoe.ca.

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Step 1 of 5

We ask that all registrants complete the following Participant Information form for 2024-25, regardless of participation in previous years. This will ensure that information remains current for the school year.

Participant Information

Participants Name

First

Last

Birthdate

Age

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 Youth programming at Empower Simcoe?

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

Medication

IMPORTANT: Please let us know about any physical, emotional, behaviour, dietary concerns, allergies or medical concerns that we should know about in order to best support the person participating.

Does the participant carry an Epi-pen for any allergies?

*Please note we do not guarantee an allergen-free environment

Additional Information

WAIVER AND CONDITIONS OF ENROLMENT

The parent/guardian(s) of the above-named participant, release the Empower Simcoe Youth Program, its Youth Facilitator, Supervisor, 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.
If the above-named participant requires medication to be administered during the duration of camp, the parent/guardian agrees to provide Empower Simcoe with clearly labeled medication in blister packaging with instructions for administration as stated on Empower Simcoe’s medication direction form. You will be contacted by a Youth Facilitator to complete this paperwork. All Medications Must Come Blister Packaged- please arrange for the youth’s medication to be blister packaged with your pharmacist and only bring what is required for the duration of the camp. Blister Packaging: arranged at the pharmacy where each dose of medication is separated by morning/afternoon/night and sealed. Please be advised that we ask this to ensure the safety of all youth and support staff involved at the camp, this policy helps reduce the risk of any medication error.
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 youth being excused from Youth Link without refund.
If it is determined that a participant requires a 1:1 support worker, the parent/guardian is responsible for arranging this support, a youth may not be invited back to our program until a suitable support is in place. All 1:1 workers must provide
REFUND POLICY: Cancellation more than two weeks prior to the start of the camp – full refund less $50.00 administration fee. Withdrawal during camp 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.

Parent/Guardian's Signature

Clear Signature

Relationship to Youth:

Order Received – Youth Program

Participant Information

Parent/Guardian Information

Emergency Contact

Medication

REQUIREMENTS FOR SUPPORT WORKERS – PLEASE READ CAREFULLY

Behavioural & Health Considerations

Health Considerations

Activities of Daily Living

DIET

PHOTOGRAPHY/MEDIA CONSENT AND RELEASE

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Order Received – Youth Program

Participant Information

Parent/Guardian Information

Emergency Contact

Medication

REQUIREMENTS FOR SUPPORT WORKERS – PLEASE READ CAREFULLY

Behavioural & Health Considerations

Health Considerations

Activities of Daily Living

DIET

PHOTOGRAPHY/MEDIA CONSENT AND RELEASE

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