Name of Applicant: *

Name of the child or teen.

Prénom

Nom de famille

Date of Birth: *

Child or teens date of birth.

MM

DD

YYYY

Address: *

Adresse 1

Adresse 2

Ville

État/Province

Code postal

Pays

Does child use an EpiPen© or puffer?

Oui

Non

Mobility Restrictions: *

Oui

Non

Toileting Needs: *

Oui

Non

Family Physician Telephone Number:

(###)

###

####

Diagnosis: *

Please check all diagnoses that apply.

Autism

ADD

ADHD

DD

Downs Syndrome

FASD

OCD

ODD

PDD

Tourette’s Syndrome

Other: (please explain below)

Does the child have a history of violent behaviours? *

Oui

Non

Is the child a flight risk? (or prone to running away?) *

Oui

Non

Does the child enjoy outings? *

Oui

Non

Primary Contact *

Prénom

Nom de famille

Telephone Number 1 *

Primary Contact: Telephone Number 1

(###)

###

####

Telephone Number 2

Primary Contact: Telephone Number 2

(###)

###

####

Adresse

Primary Contact Address (if not same as the child).

Adresse 1

Adresse 2

Ville

État/Province

Code postal

Pays

Secondary Contact

Prénom

Nom de famille

Telephone Number 1

Secondary Contact: Telephone Number 1

(###)

###

####

Telephone Number 2

Secondary Contact: Telephone Number 2

(###)

###

####

Home Address

Secondary Contact: Home Address

Adresse 1

Adresse 2

Ville

État/Province

Code postal

Pays

WAIVER: I am the parent or guardian of the above-named client and give consent to Hamilton & District Extend-A-Family to share information about this individual with Contact Hamilton and any other agency that has a relevant interest in their well-being provided staff members exercise discretion, document such correspondence, and honour confidential and personal details whenever possible: *

Oui

Non

I acknowledge that the above-named client will be engaging in activities organized and/or arranged for by Hamilton & District Extend-A-Family and that these may be outside the scope of his or her daily routine. I acknowledge that participation in such activities may expose the above-named client to the possibility of injury. I grant Hamilton & District Extend-A-Family staff and adult volunteers the authority to obtain emergency medical treatment as necessary to ensure that the above-named client is protected from further harm or injury. I agree to waive and release Hamilton & District Extend-A-Family from all claims for damages that may arise, other than by negligence of Hamilton & District Extend-A-Family, or its employees, volunteers, and agents, as a result of this child’s participation in agency events: *

Oui

Non

I give permission for this individual to travel with agency staff and/or adult volunteers to scheduled events: *

Oui

Non

I grant Hamilton & District Extend-A-Family consent to use photographs or video footage taken by agency staff or volunteers to promote our agency via internet, social networking sites, agency newsletters, brochures, and other media: *

Oui

Non

Name of Parent/Guardian *

Prénom

Nom de famille

Date of Signature: *

MM

DD

YYYY