Nom *

Name of child /teen.

Prénom

Nom de famille

Date of Birth *

Child / Teens date of birth.

MM

DD

YYYY

Adresse *

Child/teens home address.

Adresse 1

Adresse 2

Ville

État/Province

Code postal

Pays

Resides with: *

Please select whom the child/teen resides with.

Mother

Father

Grandmother

Grandfather

Guardian

Other please explain:

Diagnosis *

please select the child / teens diagnosis. (select all that apply)

Autism

ADD

ADHD

Downs Syndrome

FASD

OCD

ODD

PDD

Tourette's Syndrome

Other please explain:

Name of Family Physician *

Provide the name of your child/teen's family doctor.

Prénom

Nom de famille

Family Physician Phone Number *

(###)

###

####

Primary Contact Name *

Name of primary contact.

Prénom

Nom de famille

Primary contact address if different from the child/teen.

Adresse 1

Adresse 2

Ville

État/Province

Code postal

Pays

Phone *

Primary contacts phone number.

(###)

###

####

Mobile Phone

Primary contacts mobile phone number.

(###)

###

####

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: *

I have read and agree to the statement.

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. *

I have read and agree to the statement.

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

I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms. Participants release Hamilton Extend-A-Family, the board, employees and volunteers of all liability regarding 1) any injury to self or others and 2) any loss or damage to personal property. *

I have read and agree to the statement.

Name of Parent, Guardian, or Participant. * *

Prénom

Nom de famille

Date of Application *

MM

DD

YYYY