Thank You – Summer Adventures

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

At this program we provide a 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.

How do I know if the youth requires 1:1 supports to attend Empower Simcoe’s Youth Programs?

(If the answer is yes to any of the following, they need 1:1)
o Does the youth need assistance in the washroom?
o Does the youth struggle to transition to new activities or stay with a group?
o Is the youth a flight risk?
o Is the youth at risk of self harm or harming others?

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. 

Health Considerations

Activities of Daily Living

Please select the appropriate level of support that corresponds with the support this person most often needs for daily living activities.  These are routine activities performed every day, such as dressing, eating, socializing, participation and bathroom hygiene. This does NOT indicate the level of support they will be receiving at this program.

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.