Moorelands City Youth (VITAL) Application

Please complete the below application to apply for Moorelands City Youth (VITAL) program. If you would like to learn more about the program, click here.

Step 1 of 5

Participant Information

Participant Name *

First

Last

Most Commonly Used Name (if different from First Name)

Sex *

Grade *

As of September 2024

Date of Birth (mm/dd/yy) *

As part of our efforts to support the participants in our High School programs, we may contact them directly through email or text message. This will help them be more successful in the program. At any time, you may request a log of communication and Moorelands Kids will provide it to you. Do you give us permission to contact your child through email and/or phone? *

Participant's Mobile Phone *

Has the participant attended a Moorelands Kids program before? *

Which Moorelands City Youth (VITAL) session do you prefer? *

Thursday at 5pm
Thursday at 7pm

If your preferred time is full, can your child attend the other time? *

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Family Information

Parent 1 Name *

First

Last

Parent 1 Relationship to Child *

Parent 1 Primary Phone Number *

What type of phone number is it? *

Parent 1 Secondary Phone Number

What type of phone number is it?

Parent 1 Email *

Confirm Email

Parent 1 Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent 2 Name

First

Last

Parent 2 Relationship to Child

Parent 2 Primary Phone Number

What type of phone number is it?

Parent 2 Secondary Phone Number

What type of phone number is it?

Parent 2 Email

Confirm Email

Is the address the same as parent 1? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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CONDITIONS OF REGISTRATION

Please read the following terms and conditions of registration and sign your name below

1. I give permission for the above named child to participate fully in questionnaires or surveys, unless other-wise indicated in writing.
2. For ONLINE PROGRAMS, I understand that as parent or guardian of the above named child, I am responsible for the supervision and safety of this child in whichever setting and with whichever device I have decided is appropriate for the child to access the online program.
3. I give permission for the above named child to participate fully in both on and off site activities and trips, unless otherwise indicated in a separate note in writing.
4. I give permission for a representative from Moorelands Kids to share/obtain information about the above named child from this child’s emergency contact as indicated on this form.
5. I, on my behalf and on behalf of the above-named child, agree to the use of photographs, digital images, video or audio recordings (“Images”) of the child, without compensation, for the purposes of public education and promotion of Moorelands Kids, now or in the future. I understand that these images may be used in print publications (e.g. newsletters, print ads, etc.) and any other form of media (e.g. television, webcast, website, etc.). I agree that any such Images shall be the sole property of Moorelands Kids.
6. The City Programs Manager reserves the right to cancel a participant’s registration who in their opinion is a risk to the safety or rights of others, or who appears to have rejected the reasonable expectations of the program. The risk of safety of the rights of others extends to online interactions that may occur; usually outside of program hours.
7. Any outstanding balances from previous Moorelands Kids’ programs must be settled before your program application will be processed
8. I understand that all live video-conference sessions (“Online Program Groups”) will be recorded for safety and training purposes. All collected recordings will not be shown or used without first seeking parental permission unless it is for the purposes of training staff or ensuring the safety of both staff and participants.
9. For ONLINE PROGRAMS, I understand that any damage or loss to equipment, for example: a tablet, phone, computer, used for online programs, , is the sole responsibility of the participant and/or owner of the equipment. Moorelands Kids will not be responsible for any equipment damage that occurs during or due to the program.
10. I give permission for emergency medical treatment to be carried out, should it be required, with the understanding that Moorelands Community Services/Moorelands Kids will attempt to contact me at the telephone numbers (including the emergency contact) that I have provided on this application and any other program required form. Moorelands Kids/Moorelands Community Services will not accept financial responsibility for such services/treatment. Having taken all reasonable precautions, neither Moorelands Community Services nor any organization working with the Moorelands Community Services in a program shall be held responsible for any accident or sickness of this child.
Once registration is open, completed applications are processed as received, assessed according to resources and space available. Enrollment in the program is at the discretion of the City Programs Manager. Incomplete applications will not be processed.
I hereby certify that I have read and accept all the above conditions. The program application cannot be accepted without parent/guardian signature. MOORELANDS KIDS collects personal information about participants in its programs to be able to communicate effectively with and provide services to the families and participants served by MOORELANDS KIDS and for the purpose program development and planning. For information about MOORELANDS KIDS Privacy Policy please see our web site at www.moorelands.ca

By typing my name in the box below I agree to all the terms and conditions of registration mentioned above *

Relationship to Participant *

Date (mm/dd/yyyy) *