RCYC Intake - Staging 5

RCYC Summer Camp Registration Form 2025

Summer Camp Registration 2025

I am interested in registering for:

Your Personal Details

First Name(مطلوب)

Middle Name

Last Name(مطلوب)

Status in Canada(مطلوب)

Permanent Resident or UCI#(مطلوب)

Permanent Resident or UCI#

Date of Birth as per PR Card(مطلوب)

Gender(مطلوب)

Email Address(مطلوب)

Cell Phone

Home Phone

Work Phone Number

Native Language(مطلوب)

Other Spoken Languages (if applicable)

Date of landing

Health Card Number (MHS)(6-digit)

Personal Health Card Number (PHIN) (9-digit)

PR Card(مطلوب)

Please upload document to verify your current legal status in Canada.

أنواع الملفات المقبولة: pdf, docx, doc, jpg, gif, tiff, الحد الأقصى لحجم الملف: 10 MB.

Health Card(مطلوب)

Please upload document in case of emergency.

أنواع الملفات المقبولة: pdf, docx, doc, jpg, gif, tiff, الحد الأقصى لحجم الملف: 10 MB.

School/ Family

First time attending this program?

Are you attending other After School programs?

Are you currently attending school?

Yes

if yes which School:(مطلوب)

Name of the School

Grade:(مطلوب)

Family Size (# adults)(مطلوب)

Family Size (# children)(مطلوب)

Do you have any health concerns that RCYC staff should be aware such as: Disabilities, allergies, asthma and etc?

Yes

Please list the disabilities, allergies, asthma or other medical conditions:(مطلوب)

Current Residential Address

Address(مطلوب)

City

Province(مطلوب)

Postal Code(مطلوب)

Emergency Contact Information

Full Name(مطلوب)

Phone Number(مطلوب)

Email(مطلوب)

Relation

Photo Consent:

I hereby grant permission to the RCYC Summer Program 2025 and Resilia Community Wellness Centre to use photographs, videos, or audio recordings of myself and/or my child for reasonable and appropriate purposes. These may include, but are not limited to funding reports, promotional materials, websites, social media platforms, and public presentations. I further authorize the use of my (or my child’s) image, likeness, and voice in any promotional or documentary content whether for print, digital, video, radio, or television related to the program, without expectation of compensation.

Medical Consent and Liability Waiver:

The safety of your child/children is our primary concern. Precautions will be taken for their well-being and protection.

Client's Signature(مطلوب)

Full name OR Sign in previous box

Date(مطلوب)

If under 18:

Parent/Guardian Signature

Guardian’s Full Name OR Sign in previous box

Date

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