Thank You – March Break Bash 2024

Thank you. Your registration for March Break Bash has been started.

Please complete the Participant Information form below to complete the registration.

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- Step 1 of 4

Youth Information

Name *

First

Last

Birthdate *

Youth's Health Card Number *

Age

Expiry Date *

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 the Summer Adventure Camp?

Emergency Contact

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

Name *

First

Last

Relation to Youth *

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 youth participating.

Does the youth require medication to be given during their time at camp? (If yes, please note there is additional paperwork to be completed with an Empower Simcoe employee) *

We require all medication to be blister packaged.

Does your youth carry an Epi-pen for any allergies? *

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

Additional Information

REQUIREMENTS FOR SUPPORT WORKERS - PLEASE READ CAREFULLY

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

At March Break Bash we provide a 1:4 staffing ratio. The Youth Program recognizes that some youth may require 1:1 support, all 1:1 support workers must be arranged by the family.

Will your youth be attending the March Break Bash with a 1:1 Support Worker? *

In order for a family-employed Support Worker to accompany your youth to March Break Bash, 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)

Youth Engagement Facilitator
youth@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 your youth and how we can best support them during their week and/or day(s) with us at March Break Bash. Please complete this section in detail and include any necessary information you see as important to best support your youth. Our goal is to make your youth’s experience the most rewarding. A Youth Facilitator may connect with you to learn more about your youth if the amount of detail is insufficient or clarification is required.

Please share your youth’s behaviours and routines over the course of a day, include any concerns you may have and how we can best support your youth if they become triggered or anxious. Please include as much detail as possible.

Are there any personal care concerns that we should be made aware of? (Activities of daily living: Using the toilet, eating, etc.)

Does the youth have any hearing issues? *

Does the youth have any vision issues? *

Does the youth have any of the following health conditions? *

Seizure Disorder
Asthma
None of the above

How does the youth communicate with others? *

Speech
Sign Language
iPod/iPad
Pictures
Augmentative Communication Device

Does your youth require or use a wheelchair or other mobility aid? *

Yes
No
Occasionally

Please check the corresponding level of support most often required by your youth. This does NOT indicate the level of support they will be receiving at March Break Bash. *

Independent - the youth requires little to no support
4 youth: 1 support staff - the youth requires occasional support and guidance
1 youth: 1 support staff - the youth requires continuous support

DIET

What level of support does your youth require at meal time? *

Independent
Needs food cut up
Uses adapted utensils (please pack)

Does your youth have any food allergies, food sensitivities, or dietary restrictions? Please list.

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 my child 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 my child 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) of the above-named participant, release the March Break Bash 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.
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 day camp. Blister Packaging: arranged at the pharmacy where each dose of medication is separated by time of day. Please be advised that we ask this to ensure the safety of all youth and support staff involved at the March Break 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.
Any Medical, Emotional or Behavioural Conditions Not Fully Disclosed on This Form Could Result in The Youth Being Excused from The March Break Bash. In That Event, No Refund Will Be Issued.
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.

Name of person completing form: *

Relationship to youth: *

Signature