PD Day Registration | City of North Bay

Participant 1 Name * First and last name

Participant 1 Date of Birth *

Does Participant 1 have any health conditions, medical issues, medications, allergies, or other issues that our staff should be aware of? Please provide as much information as possible.

Do you wish to authorize Participant 1 to sign out of the PD Day Camp themselves?

Yes
No

Do you have a second participant to register? *

Yes
No

Participant 2 Name * First and last name

Participant 2 Date of Birth *

Does Participant 2 have any health conditions, medical issues, medications, allergies, or other issues that our staff should be aware of? Please provide as much information as possible.

Do you wish to authorize Participant 2 to sign out of the PD Day Camp themselves?

Yes
No

Do you have a third participant to register? *

Yes
No

Participant 3 Name * First and last name

Participant 3 Date of Birth *

Does Participant 3 have any health conditions, medical issues, medications, allergies, or other issues that our staff should be aware of? Please provide as much information as possible.

Do you wish to authorize Participant 3 to sign out of the PD Day Camp themselves?

Yes
No

Parent/Guardian name * First and last name

Parent/Guardian Address * Include street number and name, city, and postal code

Parent/Guardian Telephone Number *

Parent/Guardian Email Address *

Additional Parent/Guardian name First and last name

Additional Parent/Guardian Address Include street number and name, city, and postal code

Additional Parent/Guardian Telephone Number

Additional Parent/Guardian Email Address

Emergency Contact Name * First and last name

Emergency Contact Telephone Number *

Emergency Contact relationship to participant(s)

Photo release

During our activities, there may be times when photographs may be taken of the participants. These photos may be used for publicity purposes or may appear in local media.

By selecting yes, you hereby authorize the City of North Bay to publish photographs taken of persons under your legal guardianship for use in print, online, and municipal publications. You acknowledge that their participation is voluntary and that neither you nor the participants will receive any financial compensation for the use of these photographs. You further agree that your wards' participation in any publication, photo, or website confers upon you or your wards no rights to ownership of the original photo or the forum in which it was used. You hereby release the City of North Bay from any liability or third-party claims regarding the use of these photographs.

May the City of North Bay use photos of your child(ren) for publicity purposes? As outlined above.

Yes
No

Consent for collection, use and storing data * I acknowledge that my information will be collected, used and stored by the City

Yes, I give permission to collect, store and process my data.