Soniashnyk Cultural Learning Program

Status

01. Participant’s Details (As Given on Health Card)

Surname *

Given Name *

Parent's Email *

Health Card Number *

Date of Birth *

Paste Participant’s Photo *

Click or drag a file to this area to upload.

Photo of Participant must be in .jpg or .pdf format.

Please indicate the school your child attends *

02. Participant’s Physical Description

Sex *

Weight (kg) *

Height (cm) *

Eye Colour *

Hair Colour *

T-shirt Size *

03. Participant’s Address

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

04. Parent(s) or Guardian(s) Information With Whom Participant Resides:

Guardian #1 Full Name *

Guardian #1 Contact Number *

Guardian #1 Email *

Guardian #2 Full Name

Guardian #2 Contact Number

Guardian #2 Email

Member of the Ukrainian National Federation? *

Yes
No

If Yes, please provide UNF Membership Number: *

05. Additional Parent(s) or Guardian(s) Information

Father's (or Guardian's) Full Name

Father's (or Guardian's) Number

Father's (or Guardian's) Email

Mother's (or Guardian's) Full Name

Mother's (or Guardian's) Number

Mother's (or Guardian's) Email

Member of the Ukrainian National Federation?

Yes
No

If Yes, please provide UNF Membership Number:

Are there any court orders or custody restrictions which would prevent us from communicating with either guardian?

Yes
No

If Yes, please describe:

06. Emergency Contact Details

A minimum of two Emergency Contacts over the age of 16 are required and must be different from the parents and guardians listed above. I authorize Soniashnyk - After School Program to contact the individuals below in the event that I am not immediately available.

Emergency Contact #1 Full Name *

Relationship to Participant *

Work *

Cell *

Emergency Contact #2 Full Name *

Relationship to Participant *

Work *

Cell *

07. Participant's Physician Details

Physician's Full Name *

Physician's Number *

08. Pre-Existing Medical Conditions and Allergies

If there are any special needs, medical conditions, allergies, dietary restrictions, behavioural or physical concerns, that would interfere with the camper's camp life and activities please complete Appendix A at the end of this application.

Has the participant been exposed to any infectious diseases recently? ( Covid, chicken pox, mumps etc) *

Yes
No

I am aware that Soniashnyk Cultural Learning Program is a nut free environment but that the absence of potential allergens cannot be guaranteed. *

Agree

9. Soniashnyk Cultural Learning Program Payment Information

Are you a? *

UNF Member
Non-UNF Member

Fall Term: Sept 11 - Dec 22 (includes PA Days Oct 6, Nov 17, Dec 8)
Winter Term: Jan 8 - March 28 (includes PA Days Jan 19, Feb 16)
Spring Term: Apr 2 - June 28 (includes PA Days April 19, June 7)

Pricing:
UNF member is $28.50 per day - Monthly instalments of $541.50 (10 months)
Program does not include Stat Holidays (Oct 9, Feb 19, Mar 29, Apr 1, May 20)

Fall Term: Sept 11 - Dec 22 (includes PA Days Oct 6, Nov 17, Dec 8)
Winter Term: Jan 8 - March 28 (includes PA Days Jan 19, Feb 16)
Spring Term: Apr 2 - June 28 (includes PA Days April 19, June 7)

Pricing:
Non-UNF member is $30.00 per day - Monthly instalments of $570.00 (10 months)
Program does not include Stat Holidays (Oct 9, Feb 19, Mar 29, Apr 1, May 20)

Winter and March Breaks

We will offer a full day camp program during both breaks which will be a separate fee and registration.

$75/PA day for those who are not registered for Soniashnyk Cultural Learning Program. If you would like to sign up for PA days only, please choose out of the following dates:

10. Parent Signature and Acknowledgement Soniashnyk Cultural Learning Program:

AUTHORIZATION FOR FIELD TRIPS *

Agree

I give permissions for the Participant to leave the Camp premises to participate in field trips and I give permission to the staff of Soniashnyk to take the Camper to all scheduled trip locations during the session in which the Camper is registered. I agree that the Camper may be transported by to trip sites by school bus, public transportation or walking. I understand that the Camper will be escorted and supervised by Camp staff during this trip.

MEDICAL AUTHORIZATION AND RELEASE *

Agree

I hereby consent to any first aid treatment or medical emergency treatment being given or provided to the Participant as may be necessary or warranted under the circumstances and hereby give permission that in the case of an emergency and I cannot be immediately reached, Soniashnyk Cultural Learning Program staff may hospitalize and authorize treatment for the Participant, including but not limited to the provision of anesthetics, injections and/or surgery. I also give permission for Soniashnyk Cultural Learning Program staff to transport the Participant to the emergency department at the nearest hospital, without any liability on the part of the staff member. Furthermore, I agree to accept financial responsibility for any costs associated with the Participant receiving medical treatment. I also agree that the information in this Form and any attachments hereto can be disclosed to emergency and health personnel. I confirm that I have provided complete and accurate medical information for the Participant and permit the Participant to participate in the full range of Program activities, except as I have explicitly noted on the Medical Information Form attached hereto as Appendix "A" on page 5. I hereby agree and undertake that I will use best efforts to make myself available and be reachable at either of the phone numbers I have listed in this Form at all time.

RELEASE AND INDEMNITY *

Agree

I give permission for the Participant to participate in all Soniashnyk Cultural Learning Program activities and I understand that some of the activities, such as but not limited to, canoeing, swimming and water sports, may be inherently dangerous and/or involve risks. In consideration of the Participant’s opportunity to participate in the Soniashnyk Cultural Learning Program, the receipt and sufficient of which is hereby acknowledged, I hereby release and forever discharge the Organization in respect of any and all claims, actions, losses, damages, costs, and expenses, including but not limited to loss of income, in relation to any and all personal injury to or death of the Participant or any other person, or any loss of or damage to property, arising in any way at, from or in connection with the Soniashnyk Cultural Learning Program and services and any and all matters set out in this Registration Form, howsoever caused, and I agree to indemnify and save harmless the Organization with respect to same. I am providing this release and indemnity on behalf of the Participant, as well as in my personal capacity on my own behalf, and on behalf of my spouse and any other persons who may be entitled to assert such a claim, and agree that this waiver and indemnity shall be binding on my personal representatives, heirs and successors. I understand that although every effort is made to send Participants home with all of their belongings, the Soniashnyk Cultural Learning Program is not responsible for any loss or damage.

I have read this Form and any attachments hereto fully, and understand its terms and that I am giving up substantial rights by signing it. I have signed this form freely, voluntarily and without any inducements or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this Form and any attachments hereto are held to be invalid, the remaining terms and provisions shall continue to be in full force and effect. I confirm having been advised that I should obtain independent legal advice prior to signing the Registration Form and any attachments thereto.

MEDIA RELEASE *

Agree
Disagree

I hereby authorize any images or recordings taken of the Participant and/or me, as applicable, and any work, art or performance of the Participant(“Work”), in relation to the Participant’s participation in Soniashnyk - Soniashnyk Cultural Learning Program, to be used by the Organization for promotional, informational, publicity, and marketing purposes, and authorize the publication and/or display of said materials publicly, whether on a website, social media, television, in print or otherwise. I also consent to the release of the Participant’s name but only as it relates to the Participant’s participation in the Participant.

I hereby relinquish all rights, title, interest and royalties I and/or the Participant may have in any of the said images, recordings, and Work, and hereby release the Organization from any and all claims or demands for damages of any kind whatsoever arising from the Organization’s use of said materials. I understand that said materials may be used and may be reproduced by third parties and I agree that I will not hold the Organization responsible for any harm or damages that may arise as a result.

SONIASHNYK CULTURAL LEARNING PROGRAM POLICY *

Agree

I confirm that I have read and understand the Soniashnyk Cultural Learning Program Policies outlined in the Policy Book which were sent to me via email at time of confirmation of registration and I agree to abide by and be bound by the policies. I further confirm having reviewed the policies with the Participant. Soniashnyk Cultural Learning Program reserves the right to cancel the Participant's participation in the Soniashnyk Cultural Learning Program and any of its programming if the Participant’s behaviour is deemed unmanageable, inappropriate or dangerous in the Soniashnyk Cultural Learning Program’s sole discretion, in which case any registration fees paid will be non-refundable, and I hereby acknowledge and agree that I will be responsible for any and all costs associated with such dismissal. I also have read and understand the refund policy where no refunds or credits may be applied after registration is confirmed, whether or not the Participant has attended Soniashnyk Cultural Learning Program.

RELEASE OF INFORMATION *

Agree

I hereby agree that the information in this Form and any attachments hereto can be disclosed to the Organization as applicable in relation to the Participant’s participation in the Soniashnyk Cultural Learning Program and/or the administration of the Participant’s programming.

PRIVACY POLICY *

Agree

I agree to be contacted in regards to Soniashnyk Cultural Learning Program News and Events during, but not restricted to, the duration of participation. I acknowledge that I may remove my name from the contact lists at anytime past Soniashnyk Cultural Learning Program dates by contacting [email protected]. I understand once my name is removed I will not be contacted for early registration

SNOW DAYS AND REFUNDS *

Agree

I acknowledge that in case of a snow storm the Soniashnyk Cultural Learning Program will be cancelled for a day and I will receive a refund for that day.

11. Signature of Both Legal Guardians

By signing this Form, I confirm and acknowledge that I have carefully read and fully understand the terms in this Form and any attachments hereto, and that I irrevocably agree to the Terms set out therein.

Guardian #1 Printed Name *

Guardian #1 Signature *

Date *

Guardian #2 Printed Name

Guardian #2 Signature

Date

APPENDIX "A" - Medical and Safety Information Form

Does the Participant have any medical conditions which we should be aware of (ie. asthma, diabetes, epilepsy etc.): *

Yes
No

If “Yes” provide details of condition(s) and severity:

Does the Participant require any medications to be administered for his/her medical condition(s)? *

Yes
No

If yes, please include all medication below. All medications/puffers/injections must be in original packaging with the manufacturer’s instructions enclosed, along with the label from the pharmacy setting out the dispensing and dosage instructions.

Medication

Storage Instructions

Frequency

Dosage

Does the Participant have any allergies? *

Yes
No

Allergies

Severity

Emergency Medication

Does the Participant have any behavioural conditions/concerns which we should be aware of? (ADHD, anger management, bedwetting, social anxiety, sleep walking etc.) ? *

Yes
No

If “Yes”, please provide details of condition(s) and approved action plan.

Please list any dietary restrictions beyond allergies:

I hereby confirm that the information in this Medical Information Form is complete and accurate I confirm that I will pick up my child within 1 hour if she/he is unwell enough not to participate in the After School Program and will not send my child to After School Program if they are unwell or within 24 hours of having had a fever. I understand that no refunds will be applied for dates missed due to sickness. I authorize After School Program staff to administer any medication/puffers/injections that have been brought with the Participant to After School Program and by signing this Form, and I understand that no medications/puffers/injections are to be kept on the Participant’s person unless otherwise indicated by a doctor in writing. By signing this Form and in consideration of the Participant’s opportunity to participate in the Participant, I hereby release and forever discharge the Organization in respect of any and all claims, actions, losses, damages, costs and expenses in relation to Participant staff administering any medications/puffers/injections as set out herein, howsoever caused, and agree to indemnify and save harmless the Organization with respect to same.