Visions & Voices Forum Registration 2019 Registering YouthName:* First Last Age:*Gender* Date of Birth (mm/dd/yyyy)* MM slash DD slash YYYY Address:* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone:*Mobile Phone*Alias (known by other name) Do you have an open file with Xyolhemeylh?* Yes No If yes, who is your social worker?* Email Address:* Band you belong to:* Check all that apply:* On Reserve Off Reserve Status Non-Status First Nations Metis Inuit Other If “other” please identify:* Please tell us why you want to go to the event and what kind of activities you would like to see. This will help the planning committee make decisions.*Yes, I, , agree to participate in all events and follow all rules and guidelines of Visions and Voices.Youth Signature:**Above section must be completed by Youth Registering.Parent/Guardian InformationMother/Legal Guardian Full Name First Last Home Phone Number:Alternate Phone Number:Father/Legal Guardian Full Name First Last Home Phone Number:Alternate Phone Number:Signature of Parent/Guardian*Date:* MM slash DD slash YYYY Witness Name* First Last Witness Signature*Date:* MM slash DD slash YYYY Participation Permission Form:1. I hereby* Do Do not consent and authorize Xyólheméylh to use and reproduce photographs taken of my child and to circulate same for advertising or publicity purposes of every description. 2. It is our policy that we (Xyolhemeylh) notify a parent/guardian when a child is ill or needs medical attention. Occasionally, we are unable to contact parents/guardians and require immediate assistance for the child. Our procedure is to call an ambulance and transport your child to the nearest emergency center. 3. In the event of an injury or medical emergency, it is the policy of Xyólheméylh that the decision to call an ambulance (at the parent/guardian’s expense) rests with the trained staff on duty. 4. I hereby give consent for my child, , when ill or injured to be taken by ambulance to the nearest emergency center when I cannot be contacted. 5. I have provided the proper medical information and medical card number for my child. 6. I hereby give consent for Xyólheméylh Staff to administer the following medications to my child, listed below. All medications must be in blister packs from the pharmacy with the original prescription label. All medications must be given to the Xyólheméylh staff upon arrival to Vision & Voices. Medical InformationDoctor's Name* Doctor's Phone*Care Card #* Check All That Apply Allergic to bee/wasp stings Asthma Diabetes Recurring Headaches Seizures Black-Outs Chest Pain Heart Disease Mental Health Suicide Ideology Schizophrenia Other Other:* Is Your Child Taking Any Medication?* Yes No (Please list medications below.)Does Your Child Have Any Special Needs?* Yes No Madication Incformation*Medication NameWhen It Is GivenAmount or DoseHow It Is Given Please identify any complex behaviours and/or developmental delays:Do you need transportation?* Yes No What is your hoodie size?*Please select a size...XSMLXLXXLEmergency Contact Information:Will you be available in case of emergency?* Yes No Please provide two emergency contact names and phone numbers we can call if there is an emergency:Contact Name #1:* Phone:*Contact Name #2:* Phone:*Signature Of Parent/Guardian*Date:* MM slash DD slash YYYY Please ensure your child is free from any communicable diseases or contagious diseases (examples: flu, scabies, pink eye, strep throat, head lice, etc) If your child arrives at Vision & Voices with a communicable disease they will be sent home.Additional InformationTell us anything else you'd like us to know.Code of ConductThis contract must be signed and dated by the participant and a parent/legal guardian. This contract is designed to help participants and parents/guardians understand the expectations of the participants. Please read carefully, sign and date this form then return to Xyólheméylh attention Vision and Voices with the completed registration form, participant permission form and waiver form. I, , agree to abide by the following: I will promote a positive, productive, and supportive environment for the group. I will notify Xyólheméylh employees of any injury or illness. I will refrain from using foul and demeaning language. I will not use any alcohol, cigarettes or drugs other than medication prescribed to me by a doctor. I understand that if I use alcohol, cigarettes or drugs I will be sent home as soon as possible at my own expense. I understand that it will be the decision of Xyólheméylh employees that if any term of this contract is broken I will be sent home immediately. I understand that my Parents/Guardians/Emergency Contact persons will be contacted AT ANY TIME of the day or night in the event I am returning home due to an emergency or failure to abide by the Code of Conduct. I, , Visions & Voices Registrant, have read and understand all of the forms provided. I acknowledge and accept full responsibility as described above. Signature of Youth Registering:*Please draw your signature within the box.Signature of Parent Guardian:*Please draw your signature within the box.Date:* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
