IRCOM - ASP & HEY Registration Form Child First Name(Required) Child Last Name(Required) Gender(Required)MaleFemaleNon-BinaryUnknownAddress(Required) Postal Code(Required) Phone (Cell)(Required) Phone (Home) Phone (Other) Immigration Status(Required)Canadian CitizenGovernment Assisted Refugees (GAR)Private Sponsored Refugees (PSR)Refugee Claimant (RC)Provincial NomineeUkraine CUAET PermitPermanent ResidentProtected PersonCountry of Origin(Required)Abu DhabiAfghanistanAlbaniaAlderneyAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua / BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas Is.BahrainBangladeshBarbadosBelarusBelgiumBelizeBenin Peoples RepublicBermudaBhutanBoliviaBophuthatswanaBosnia and HerzegovinaBotswana Republic OfBrazilBrechouBrit. Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCayman IslandsCent. African RepublicChad Republic OfChileChina (PRC)ColombiaComorosCongo Democratic Republic ofCongo Republic OfCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominican RepublicEcuadorEgyptEl SalvadorEnglandEquatorial GuineaEritreaEstoniaEthiopiaFalkland Is.Federal Rep. Of GermanyFijiFinlandFormosaFr. PolynesiaFranceFrench GuianaGabon RepublicGambiaGeorgiaGhanaGibraltarGreeceGreenlandGrenadaGuadaloupeGuamGuatemalaGuinea RepublicGuinea-bissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesia Republic OfIranIraqIreland, Republic ofIsraelItalyIvory Coast RepublicJamaicaJapanJordanKampuchea DemocraticKazakhstanKenyaKerguelen IslandsKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldives, Republic OfMali, Republic OfMaltaMarshall Is.MartiniqueMauritaniaMauritiusMayotteMexicoMoldovaMonacoMongolia People's RepublicMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands, Ant.NevisNew CaledoniaNew ZealandNicaraguaNiger RepublicNigeriaNorthern IrelandNorwayOmanPakistanPalestinePanamaPanama Canal ZonePapua New GuineaParaguayPeruPhilippinesPitcairn Is.PolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSamoaSan MarinoSao Tome E PrincipeSaudi ArabiaScotlandSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomons, TheSomaliaSouth Africa, Republic OfSouth SudanSpainSri LankaSt.HelenaSt.Kitts-nevisSt.LuciaSt.Pierre Et MiquelonSt.Vincent And The GrenadinesStatelessSudan Dem. Rep. OfSurinameSwazilandSwedenSwitzerlandSyriaTaiwan (ROC)TajikistanTanzania, United Republic OfThailandTibetTogo Republic OfTongaTrinidad & Tobago Dem. Rep. OfTunisiaTurkeyTurkmenistanTurks & CaicosTuvaluU.S. Virgin Is.UgandaUkraineUnited Arab EmiratesUnited KingdomUnited States Of AmericaUruguayUzbekistanVanuatuVatican City St.VenezuelaVietnamWalesWallis And FutunaWestern SaharaYemen, Republic OfYugoslaviaZaire, Republic OfZambiaZimbabwePermanent Resident Card# (8 or 10 digits) Date of Birth (As per PR Card)(Required) DD slash MM slash YYYY Current School GradeGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Student Number MHSC Health Insurance (P.H.I.N.)9 digits Registration number6 digits Parent/Guardian - Full Name(Required) Phone(Required) Emergency Contact - Full Name Phone Select the Program(s) you want to be involved whithChildren's Program (6-12 years)Homework Club (12-18 years)Youth Program (12-18 years)Health Information About the ChildPlease fill out any of the following that apply. The more information that we have allows us to better meet the needs of your child. Child has AllergiesCarries an EpipenChild Has AsthmaCarries an InhalerChild wears a medic-alert braceletMore detailsPlease 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 PermissionI 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.(Required)YesNoGeneral PermissionI 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.(Required)YesNoPhotograph ApprovalI 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. (Required)YesNoParent/Guardian's SignatureSign Date DD slash MM slash YYYY 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 SignatureSign Date DD slash MM slash YYYY 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 GuardianSign Date DD slash MM slash YYYY Witness (IRCOM staff)Sign Date DD slash MM slash YYYY HiddenFor IRCOM Administrative Use OnlyHiddenToday's Date MM slash DD slash YYYY HiddenProgram HiddenConsent1 HiddenConsent2 HiddenConsent3 HiddenConsents NameThis field is for validation purposes and should be left unchanged.