BBBSPY and LAMP’s Rise and Belong: Wellness Program for Newcomer Youth in Grades 9-12

Big Brothers Big Sisters of Peel York and LAMP Community Health Centre (East Mississauga) are excited to present “Rise and Belong”, a FREE Wellness program for Newcomer Youth in Grades 9-12, at Hazel McCallion Central Library Open Window Hub, every Friday from July 11th to Aug 22nd, from 10am to 11:30am. Free drop in counselling with a Social Worker available from 11:30am to 1:30pm.

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Youth's Name*
MM slash DD slash YYYY
Youth's Grade
First and Last
Relation to Youth*

I am the parent/guardian of the youth for whom I am making this application*
Family Address*
Does your child have any medical or behavioral needs that we should be aware of?*
We realize that this information can be of a sensitive nature and it will be treated with confidence and respect.
Does your child have any food allergies or dietary restrictions?*
Light snacks will be provided during each session.
Ex. religious or cultural views, stressors, other existing issues?

Media Consent

I hereby consent to Big Brothers Big Sisters of Peel York (BBBSPY) and LAMP Community Health Centre, the use of any photographs, audio and/or video recordings of my child taken during the program as authorized by the BBBSPY President & CEO or Board of Directors. I give my permission for this media to be used by BBBSPY and LAMP for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the BBBSPY and LAMP's website and social media). Photographs or video productions may also be shared with community and school partners for program promotion.*

BBBSPY's Informed Consent

I hereby give permission to Big Brothers Big Sisters of Peel York to make available their service to my child. It is my understanding that the intention of the Agency is to offer my child an opportunity to participate in a group program lead by a responsible adult, (minimum 18 years old, however, where appropriate supervision takes place, the volunteer may be younger), I understand that all efforts will be made to select a responsible Mentor who will facilitate the group program. In consideration for this service and other valuable consideration provided to my child by Big Brothers Big Sisters of Peel York, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself or my child. I permit the agency to release any relevant information, including my personal information, to Big Brothers Big Sisters of Canada and their insurers, as may be appropriate in connection with any legal proceeding, inquiry or risk thereof. I understand that the collection of personal information about me or my child will be held in strict confidence and is to be used solely for the purposes of administering the program. I further agree that information about my child may be shared, at the discretion of Big Brothers Big Sisters of Peel York, with the group facilitator so that my child’s needs may be best met. I understand that this application is the property of Big Brothers Big Sisters of Peel York. I also agree that my child will participate in the Pre- Match Training Program administered by Big Brothers Big Sisters of Peel York.*

LAMP's Participation & Release of Liability Waiver:

I recognize that this program/activity requires physical effort, which may be strenuous and may cause injury, and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a primary care provider prior to and regarding participation in this activity. In consideration of being permitted to participate in this activity, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which might be incurred as a result of participating. I, the undersigned, hereby release, waive, forever discharge, hold and save harmless and agree to protect LAMP Community Health Centre and its employees, agents, representatives, administrators, officials and servants of LAMP Community Health Centre from all claims, demands, damages, costs, expenses, actions and causes of action, in respect to death, injury, loss or damage to my person, person(s) participating under my authority or property however caused, arising as a result of or in any way connected with participation in the event, as a participant or otherwise, whether prior to, during or after the event.*
Clear Signature

STATISTICAL INFORMATION:

Immigration Number:
Immigration Status:
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