Summer Youth Centre Registration

Please note that completing a form does not guarantee registration. Staff will contact you to confirm your child(ren)'s spot in this program.

Fields marked * are mandatory.

Which location will your child(ren) be attending? *

Caldwell-Ellam Community Centre
Elmwood Community Hub

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)

Authorized Pickup

Our staff will allow any person listed as a Parent/Guardian or Emergency Contact to pick up the participant(s).

Please provide information for any authorized person, other than parents/guardians and emergency contacts, who may also sign the participant(s) out.

Authorized Pickup Person First and last name

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

Permission for beach

On Fridays, staff and participants of Summer Youth Centre take part in Beach Days, where we use North Bay Transit to travel to Shabogesic Beach. Lifeguards will administer swim tests on those participants with permission to swim, and those who pass will be permitted to swim without a lifejacket.

Do you give your child/children permission to swim during Beach Days? * 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.