Erin Mills Youth Centre
3010 The Collegeway, Mississauga ON L5L 4X9
Tel. 905-820-3577 Fax 905-820-7087
www.erinmillsyouthcentre.com
Participant Registration Form
A) PROGRAM : HOMELANDS AFTER SCHOOL
Please select the days in which your child/children will be present at program.
 Monday
 Tuesday
 Wednesday
 Thursday
B) PARTICIPANT INFORMATION
First Name
Last Name
Date of Birth (dd/mm/yyyy)
Gender
Current Grade
School
☐ Male
☐ Female
Please provide any information regarding the participant that may be helpful to staff.
Allergies:
Medication:
Carries Medics Alert
Carries EPI–Pen
Carries Puffer
Special Needs:
Yes 
Yes 
Yes 
No 
No 
No 
Erin Mills Youth Centre
C)
Participation Registration
PARENT/GUARDIAN INFORMATION
Last Name
First Name
Home Phone
Cell Phone
Address
Postal Code
Email:
Child’s Residence:
Yes 
No 
Last Name
First Name
Home Phone
Cell Phone
Address
Postal Code
Email:
Child’s Residence:
Yes 
No 
D) EMERGENCY CONTACT INFORMATION
(IN ADDITION TO PARENT/GUARDIAN)
Last Name
First Name
Home Phone
Cell Phone
Last Name
First Name
Home Phone
Cell Phone
E) SAFE DISMISSAL
Choose ONE:
 My child may walk home alone at _________ p.m.
 My child will be picked up at the program by a parent/guardian or other authorized
individual.
 My child will take the provided bus home (if applicable).
Participant Registration – Page 2 of 4
Erin Mills Youth Centre
Participation Registration
Participants will only be released to the Parent/Legal Guardians, Emergency
Contacts and to those individuals listed below on this form. List anyone who is
authorized to pick up your child. Photo I.D. will be requested.
Last Name
First Name
Home Phone
Cell Phone
Last Name
First Name
Home Phone
Cell Phone
F) MEDICAL AUTHORIZATION
On behalf of the participant listed above (section B):
1. I give permission to have staff administer or arrange for any emergency medical care
including hospitalization/transportation if necessary.
2. I consent to the administration of such emergency medical treatment as may be deemed
necessary in the circumstances.
3. I understand that all participants are responsible for their own medical coverage.
Parent/Guardian Initial__________________________
Date: ______________________
G) WALKING CONSENT
 I agree that my child listed above (section B) may go on walks around the neighbourhood
as a part of the regularly scheduled program activities.
Parent/Guardian Initial__________________________
Date: ______________________
H) PHOTOGRAPHY CONSENT
Please check ONE box.
 I agree that my child listed above (section B) may be photographed/videotaped during the
program and/or special events. Any images taken of my child may be used for educational
or promotional materials, including the Erin Mills Youth Centre website and social media
platforms.
 My child listed above (section B) may not be photographed.
Parent/Guardian Initial__________________________
Participant Registration – Page 3 of 4
Date: ______________________
Erin Mills Youth Centre
I)
Participation Registration
Terms of Agreement
1. I have read through the application and confirm that all the above information is correct
and my statements represent my decisions for my child
2. I have specified above who has permission or have given permission for them to walk
home. In either situation, I assume all responsibility for my child and their safety
3. I understand that any recreational activity (including all aspects programming) involves risk
to my child including personal injury, property loss and/or damage
4. I voluntarily agree to assume the risk and waive any rights of action, claims, and/or
demands I may have against EMYC, and its associates for any reason including personal
injury, property loss or damage caused by negligence on the part of EMYC, its agents,
employees or volunteers.
5. I consent to my child completing surveys and/or participating in program evaluation
6. I read and understand the above and hereby grant permission on these items for my child
to participate in the EMYC activities
Parent/Guardian Name _________________________________________________________
Signature: ___________________________________
J)
Date: ______________________
Stay Informed
Erin Mills Youth Centre would like to keep you informed of our programs and events
Email Address ________________________________________________________________
Would you like to know about volunteer opportunities?
Yes 
No 
My areas of interest for volunteering:
 Program Assistant
 Breakfast Program
 Board Member
 Fundraising
 Other _______________________
FOR OFFICE USE ONLY:
 Registration Form completed and signed  Ontario Health Card Number valid (if applicable)
 Registration Fee
Received By/Date
 Details provided regarding special needs
Entered By/Date
Participant Registration – Page 4 of 4