IRCOM - ASP & HEY Registration Form

Child First Name(Required)

Child Last Name(Required)

Gender(Required)

Address(Required)

Postal Code(Required)

Phone (Cell)(Required)

Phone (Home)

Phone (Other)

Immigration Status(Required)

Country of Origin(Required)

Permanent Resident Card# (8 or 10 digits)

Date of Birth (As per PR Card)(Required)

Current School

Grade

Student Number

MHSC Health Insurance (P.H.I.N.)

9 digits

Registration number

6 digits

Parent/Guardian - Full Name(Required)

Phone(Required)

Emergency Contact - Full Name

Phone

Select the Program(s) you want to be involved whith

Health Information About the Child

Please fill out any of the following that apply. The more information that we have allows us to better meet the needs of your child.

More details

Please provide the name, details, symptoms and triggers of the condition/allergy. Please also include a management plan and dosage requirements if medication is required.

Emergency Care and Transportation Permission

I recognize that participation in IRCOM activities may expose my child to risk of injury. I agree not to hold IRCOM Inc. liable to any claims that may occur during any activity at IRCOM, or in its programs. I hereby grant IRCOM’s director and/or staff permission to secure proper medical treatment and transportation for my child to an appropriate facility for treatment, in case of emergency, and/or when I am unable to be contacted.

General Permission

I hereby give permission for my child to participate in IRCOM’s After-School programs, including sports and recreation, homework, peer support and health workshops. I understand that my child may be suspended or expelled from this Program for fighting, or other disciplining reasons determined by program staff and/or director. I understand that IRCOM Inc. does not provide daycare services, and children are free to come and go as they please. I understand that should my child leave while attending the program, she/he is no longer in care of the program staff.

Photograph Approval

I hereby authorize the IRCOM staff to take photographs of my child named in this application during program activities, and to display and otherwise use these photographs without charge, and solely for the purpose of promoting and reporting on programs at IRCOM.

Parent/Guardian's Signature

Sign Date

Off-Site Programs and activities Permission

This is to certify that I allow my child to attend off-site activities through the Immigrant and Refugee Community Organization of Manitoba (IRCOM) Inc. These activities may include, but are not limited to homework, sports games and practices, gym, community events, swimming, bowling, movies etc.

I am aware that all youth participating in these programs will be supervised at all times by staff members and volunteers of IRCOM Inc. I agree that IRCOM Inc.is not responsible for any loss or damage to personal property or bodily injury suffered by the youth before during or after the activity.

Parent/Guardian's Signature

Sign Date

Homework, Education and Youth Consent to Share Information

The Homework, Education and Youth (HEY) Program is part of the after school programs of the Immigrant and Refugee Community Organization of Manitoba (IRCOM) Inc. and works in partnership with Winnipeg schools. HEY program staff may speak with staff of the participant’s school (e.g. teachers, guidance, administrators) when appropriate to support the youth and his/her family to achieve academic and social goals.

I give permission to the Homework, Education and Youth Program to share information with staff of my child’s school or other programs of IRCOM as necessary to ensure that my child receives appropriate education and social support, programming and is able to successfully participate in and benefit from the HEY Program.

I understand that information regarding my child’s school attendance and academic progress including course grades, as well as participation in HEY tutoring, literacy, leadership mentoring and enrichment may be shared with IRCOM staff and mentors when necessary, to support participation and success in the HEY Program.

I understand that the HEY Program will not release information to any other person or agency without my consent, except when required by law.

I have read and agreed to the above terms:

Signature of Guardian

Sign Date

Witness (IRCOM staff)

Sign Date