RCYC Intake - Staging 5

RCYC Summer Camp Registration Form 2025

Summer Camp Registration 2025

I am interested in registering for:

Your Personal Details

Prénom(Nécessaire)

Middle Name

Nom de famille(Nécessaire)

Status in Canada(Nécessaire)

Permanent Resident or UCI#(Nécessaire)

Permanent Resident or UCI#

Date of Birth as per PR Card(Nécessaire)

Genre(Nécessaire)

Email Address(Nécessaire)

Cell Phone

Home Phone

Work Phone Number

Langue maternelle(Nécessaire)

Other Spoken Languages (if applicable)

Date of landing

Health Card Number (MHS)(6-digit)

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

PR Card(Nécessaire)

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

Types de fichier acceptés : pdf, docx, doc, jpg, gif, tiff, Taille maximum des fichiers : 10 MB.

Health Card(Nécessaire)

Please upload document in case of emergency.

Types de fichier acceptés : pdf, docx, doc, jpg, gif, tiff, Taille maximum des fichiers : 10 MB.

School/ Family

First time attending this program?

Are you attending other After School programs?

Are you currently attending school?

Oui

Non

if yes which School:(Nécessaire)

Name of the School

Grade:(Nécessaire)

Family Size (# adults)(Nécessaire)

Family Size (# children)(Nécessaire)

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

Oui

Non

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

Current Residential Address

Adresse(Nécessaire)

City

Province(Nécessaire)

Code Postal(Nécessaire)

Emergency Contact Information

Full Name(Nécessaire)

Phone Number(Nécessaire)

E-mail(Nécessaire)

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(Nécessaire)

Full name OR Sign in previous box

Date(Nécessaire)

If under 18:

Parent/Guardian Signature

Guardian’s Full Name OR Sign in previous box

Date

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