Wellness Warriors at Crystal Ladder

Wellness Warriors at CLLC – Registration Form

Big Brothers Big Sisters of Peel York is excited to work with The Crystal Ladder Learning Centre this summer! Your child has been invited to participate in our free Wellness Warriors program. This program is designed to help young people build social-emotional competencies that support interpersonal connection, advocacy, problem solving, positive self-esteem, and a sense of belonging. All activities will take place at The Centre during regularly scheduled camp times. Crystal Ladder staff will be present and engaged throughout.

"*" indicates required fields

Child's Name*

First Last

Child's Date of Birth*

Child's Gender Identity

This response is voluntary.

Parent/Guardian's Full Name*

First and Last

Parent/Guardian's Email Address*

Family Address*

Street Address Address Line 2 City Postal Code

We want this program to be as beneficial as possible for all participants. If you have any suggestions on ways to best engage your child, please share those below.

Is there any other information you would like the Mentors/volunteers to know about your child?

Ex. religious or cultural views, stressors, other existing issues?

Media Consent

I hereby consent to Big Brothers Big Sisters of Peel York (BBBSPY), 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 for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the BBBSPY website and social media). Photographs or video productions may also be shared with community and school partners for program promotion.*

Yes, I give Media Consent

No, I do not give Media Consent

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.*

Yes. I have read and understand this agreement. I acknowledge that I am the parent/guardian of the child for whom I am applying and that I hereby request Big Brothers Big Sisters service for my child. I give my child permission to participate in one or more group programs offered by BBBSPY. I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for my child.

Parent/Guardian Signature*

OPTIONAL SECTION: STATISTICAL INFORMATION

At Big Brothers Big Sisters of Peel York, statistical information is requested from volunteers and families for the purpose of better understanding the community in which we serve, and for acquiring funding from community supporters and donors. This allows us to provide culturally responsive and high-quality services at no cost.

Please note: Filling out this form is optional. If you choose to complete it, the information you provide below will be kept confidential and will in no way affect your child’s eligibility to participate in our program(s).

Language(s) spoken

Child's Birth Place

Canada

Other

If your child was born outside of Canada, please provide the year they moved to Canada.

Please select the ethnic/cultural origin that you feel best describes your child or use the next field to enter it directly.

If none of the options above accurately reflect your child's identity, please feel free to add a note here:

What is the total annual household income?

Comments

This field is for validation purposes and should be left unchanged.