Game On! Registration Form

Game On! Registration is now open. If you have any questions, contact Shelby Moore

Game On Registration

THANK YOU FOR YOUR INTEREST IN OUR PROGRAM. ONCE YOUR SUBMISSION HAS BEEN REVIEWED BY OUR TEAM, YOU WILL RECEIVE AN EMAIL CONFIRMATION WITH MORE DETAILS.

Youth Name*
First Last
Youth's Birthdate*
MM slash DD slash YYYY
Youth's Ethnic Identity
Youth's School*
Youth's School Involvement*
Other
Parent or Guardian Name*
First Last
Relation to Youth*
Other
Parent/Guardian's Phone Number*
Parent/Guardian's E-mail Address*
I am the parent/guardian of the youth for whom I am making this application.*
- Yes
- No
Family Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does your child have any medical or behavioral needs that we should be aware of?*
Does your child have any medical or behavioral needs that we should be aware of? We realize that this information can be of a sensitive nature and it will be treated with confidence and respect.
If yes, please provide details.
Are there any adaptations that can be made with regard to these needs in order to best support your child?
Child's health card number*

In person programming only*
Emergency Contact Name*

MUST BE DIFFERENT FROM PRIMARY CONTACT
Emergency Contact Realtionship*
Emergency Contact Phone Number*
Does your child have any food allergies or restrictions?*
If yes, please provide details.
Is there any other information you would like the Mentors/volunteers to know about your child?
Ex. religious or cultural views, stressors, other existing issues?
MEDIA CONSENT
I hereby consent to Big Brothers Big Sisters of North Simcoe (BBBSNS), the use of any photographs, audio and/or video recordings of my child taken during the program as authorized by the BBBSNS President & CEO or Board of Directors. I give my permission for this media to be used by BBBSNS for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the BBBSNS website and social media). Photographs or video productions may also be shared with community and school partners for program promotion.
Please select your response to the Media Consent statement listed above*
INFORMED CONSENT
INFORMED CONSENT I hereby give permission to Big Brothers Big Sisters of North Simcoe (BBBSNS) to make available their service to my child. It is my understanding that the intention of the Agency is to offer my child an opportunity to participate in a group program lead by a responsible adult, (minimum 18 years old), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program. In consideration for this service and other valuable consideration provided to my child by BBBSNS, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my child. I permit the agency to release any relevant information, including my personal information, to Big Brothers Big Sisters of Canada and their insurers, as may be appropriate in connection with any legal proceeding, inquiry or risk thereof. I understand that the collection of personal information about me or my child will be held in strict confidence and is to be used solely for the purposes of administering the program. I further agree that information about my child may be shared, at the discretion of BBBSNS, with the group facilitator so that my child’s needs may be best met. I understand that this application is the property of BBBSNS. I also agree that my child will participate in the Pre- Match Training Program administered by BBBSNS.
I have read and understand this agreement. By checking YES, I acknowledge that I am the parent/guardian of the child for whom I am applying and that I hereby request Big Brothers Big Sisters service for my child. I give my child permission to participate in one or more group programs offered by BBBSNS. I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for my child.*

Game On! Registration Form

Game On Registration

MEDIA CONSENT

INFORMED CONSENT