IRCOM – ASP & HEY IRCOM - ASP & HEY Registration Form URLयह फ़ील्ड सत्यापन उद्देश्यों के लिए है और इसे अपरिवर्तित छोड़ दिया जाना चाहिए।Child First Name(आवश्यक)Child Last Name(आवश्यक)लिंग(आवश्यक)पुरुषमहिलानॉन बाइनरीअज्ञातपता(आवश्यक)डाक कोड(आवश्यक)Phone (Cell)(आवश्यक)Phone (Home)Phone (Other)आव्रजन स्थिति(आवश्यक)कनाडाई नागरिकसरकारी सहायता प्राप्त शरणार्थी (जीएआर)निजी प्रायोजित शरणार्थी (पीएसआर)शरणार्थी दावेदार (आरसी)Provincial Nomineeयूक्रेन CUAET परमिटस्थायी निवासीसंरक्षित व्यक्तिCountry of Origin(आवश्यक)Abu Dhabiअफ़ग़ानिस्तानअल्बानियाआइल ऑफ़एलजीरियाअमेरिकी समोआएंडोराअंगोलाएंगुइलाAntigua / Barbudaअर्जेंटीनाआर्मीनियाअरूबाऑस्ट्रेलियाऑस्ट्रियाआज़रबाइजानBahamas Is.बहरीनबांग्लादेशबारबाडोसबेलोरूसबेल्जियमबेलीज़Benin Peoples Republicबरमूडाभूटानबोलीवियाबोफुथात्स्वानाबोस्निया और हर्जेगोविनाBotswana Republic Ofब्राज़िलBrechouBrit. Virgin Islandsब्रुनेईबुल्गारियाबुर्किना फासोबुस्र्न्दीकंबोडियाकैमरूनकनाडाकैनेरी द्वीप समूहCape Verdeकेमन द्वीपसमूहCent. African RepublicChad Republic Ofचिलीचीन (पीआरसी)कोलंबियाकोमोरोसकांगो लोकतांत्रिक गणराज्यCongo Republic Ofकुक द्वीपसमूहकोस्टा रिकाक्रोएशियाक्यूबासाइप्रसCzech Republicडेनमार्कज़िबूटीडोमिनिकन गणराज्यइक्वेडोरमिस्रअल साल्वाडोरइंगलैंडभूमध्यवर्ती गिनीइरिट्रियाएस्तोनियाइथियोपियाFalkland Is.Federal Rep. Of Germanyफ़िजीफिनलैंडFormosaफादर पोलिनेशियाफ्रांसफ्रेंच गयानाGabon Republicगाम्बियाजॉर्जियाघानाजिब्राल्टरयूनानग्रीनलैंडग्रेनेडाग्वाडालूपगुआमग्वाटेमालाGuinea Republicगिनी-बिसाऊगुयानाहैतीहोंडुरसहांगकांगहंगरीआइसलैंडभारतIndonesia Republic OfईरानइराकIreland, Republic ofइजराइलइटलीIvory Coast Republicजमैकाजापानजॉर्डनकंपूचिया डेमोक्रेटिककजाखस्तानकेन्याकेर्गुएलन द्वीप समूहकिरिबातीKorea NorthKorea Southकोसोवोकुवैटकिर्गिज़स्तानलाओसलातवियालेबनानलिसोटोलाइबेरियालीबियालिकटेंस्टाइनलिथुआनियालक्समबर्गमकाओMacedoniaमेडागास्करमलावीमलेशियाMaldives, Republic OfMali, Republic Ofमाल्टाMarshall Is.मार्टीनिकमॉरिटानियामॉरीशसमैयटमेक्सिकोमोलदोवामोनाकोMongolia People's Republicमोंटेसेराटमोरक्कोमोज़ाम्बिकम्यांमारनामिबियानाउरूनेपालनीदरलैंडNetherlands, Ant.Nevisनया केलडोनियान्यूज़ीलैंडनिकारागुआNiger Republicनाइजीरियाउत्तरी आयरलैंडनॉर्वेओमानपाकिस्तानफिलिस्तीनपनामाPanama Canal Zoneपापुआ न्यू गिनीपरागुआपेरूफिलिपींसPitcairn Is.पोलैंडपुर्तगालप्यूर्टो रिकोकतररीयूनियनरोमानियारूसरवांडासमोआसैन मारिनोSao Tome E Principeसऊदी अरबस्कॉटलैंडसेनेगलसर्बियासेशल्ससेरा लिओनसिंगापुरस्लोवाकिया (स्लोवाक गणराज्य)स्लोवेनियाSolomons, TheसोमालियाSouth Africa, Republic Ofदक्षिण सूडानस्पेनश्रीलंकाSt.HelenaSt.Kitts-nevisSt.LuciaSt.Pierre Et MiquelonSt.Vincent And The Grenadinesराज्यविहीनSudan Dem. Rep. OfसूरीनामSwazilandस्वीडनस्विट्ज़रलैंडसीरियाताइवान (आरओसी)तजाकिस्तानTanzania, United Republic Ofथाईलैंडतिब्बतTogo Republic OfटोंगाTrinidad & Tobago Dem. Rep. Ofट्यूनीशियाटर्कीतुर्कमेनिस्तानतुर्क और कैकोसतुवालूU.S. Virgin Is.युगांडायूक्रेनसंयुक्त अरब अमीरातयूनाइटेड किंगडमUnited States Of Americaउरुग्वेउज़्बेकिस्तानवानुअतुVatican City St.वेनेज़ुएलावियतनामवेल्सWallis And Futunaपश्चिमी सहाराYemen, Republic Ofयूगोस्लावियाZaire, Republic Ofजाम्बियाज़िम्बाब्वेPermanent Resident Card# (8 or 10 digits)Date of Birth (As per PR Card)(आवश्यक) डीडी स्लैश एमएम स्लैश वाईवाईवाईवाई Current Schoolश्रेणीग्रेड 1ग्रेड 2ग्रेड 3ग्रेड 4ग्रेड 5वर्ग 6श्रेणी 7कक्षा 8श्रेणी 9ग्रेड 10ग्रेड 11कक्षा 12Student NumberMHSC Health Insurance (P.H.I.N.)9 digitsRegistration number6 digits Parent/Guardian - Full Name(आवश्यक)फ़ोन(आवश्यक)Emergency Contact - Full Nameफ़ोनSelect the Program(s) you want to be involved whithChildren's Program (6-12 years)Homework Club (12-18 years)Youth Program (12-18 years)Health Information About the ChildPlease fill out any of the following that apply. The more information that we have allows us to better meet the needs of your child. Child has AllergiesCarries an EpipenChild Has AsthmaCarries an InhalerChild wears a medic-alert braceletMore detailsकृपया स्थिति का नाम, विवरण, लक्षण और ट्रिगर्स बताएं। यदि दवा की आवश्यकता है तो कृपया प्रबंधन योजना और खुराक की आवश्यकताएं भी शामिल करें।Emergency Care and Transportation PermissionI recognize that participation in IRCOM activities may expose my child to risk of injury. I agree not to hold IRCOM Inc. liable to any claims that may occur during any activity at IRCOM, or in its programs. I hereby grant IRCOM’s director and/or staff permission to secure proper medical treatment and transportation for my child to an appropriate facility for treatment, in case of emergency, and/or when I am unable to be contacted.(आवश्यक)हाँनहींGeneral PermissionI hereby give permission for my child to participate in IRCOM’s After-School programs, including sports and recreation, homework, peer support and health workshops. I understand that my child may be suspended or expelled from this Program for fighting, or other disciplining reasons determined by program staff and/or director. I understand that IRCOM Inc. does not provide daycare services, and children are free to come and go as they please. I understand that should my child leave while attending the program, she/he is no longer in care of the program staff.(आवश्यक)हाँनहींPhotograph ApprovalI hereby authorize the IRCOM staff to take photographs of my child named in this application during program activities, and to display and otherwise use these photographs without charge, and solely for the purpose of promoting and reporting on programs at IRCOM. (आवश्यक)हाँनहींParent/Guardian's SignatureSign Date डीडी स्लैश एमएम स्लैश वाईवाईवाईवाई Off-Site Programs and activities Permission This is to certify that I allow my child to attend off-site activities through the Immigrant and Refugee Community Organization of Manitoba (IRCOM) Inc. These activities may include, but are not limited to homework, sports games and practices, gym, community events, swimming, bowling, movies etc. I am aware that all youth participating in these programs will be supervised at all times by staff members and volunteers of IRCOM Inc. I agree that IRCOM Inc.is not responsible for any loss or damage to personal property or bodily injury suffered by the youth before during or after the activity.Parent/Guardian's SignatureSign Date डीडी स्लैश एमएम स्लैश वाईवाईवाईवाई Homework, Education and Youth Consent to Share Information The Homework, Education and Youth (HEY) Program is part of the after school programs of the Immigrant and Refugee Community Organization of Manitoba (IRCOM) Inc. and works in partnership with Winnipeg schools. HEY program staff may speak with staff of the participant’s school (e.g. teachers, guidance, administrators) when appropriate to support the youth and his/her family to achieve academic and social goals. I give permission to the Homework, Education and Youth Program to share information with staff of my child’s school or other programs of IRCOM as necessary to ensure that my child receives appropriate education and social support, programming and is able to successfully participate in and benefit from the HEY Program. I understand that information regarding my child’s school attendance and academic progress including course grades, as well as participation in HEY tutoring, literacy, leadership mentoring and enrichment may be shared with IRCOM staff and mentors when necessary, to support participation and success in the HEY Program. I understand that the HEY Program will not release information to any other person or agency without my consent, except when required by law. I have read and agreed to the above terms:Signature of GuardianSign Date डीडी स्लैश एमएम स्लैश वाईवाईवाईवाई Witness (IRCOM staff)Sign Date डीडी स्लैश एमएम स्लैश वाईवाईवाईवाई फ़ॉर्म देखते समय यह फ़ील्ड छिपा हुआ होता हैFor IRCOM Administrative Use Onlyफ़ॉर्म देखते समय यह फ़ील्ड छिपा हुआ होता हैToday's Date एमएम स्लैश डीडी स्लैश वाईवाईवाईवाई फ़ॉर्म देखते समय यह फ़ील्ड छिपा हुआ होता हैकार्यक्रमफ़ॉर्म देखते समय यह फ़ील्ड छिपा हुआ होता हैConsent1फ़ॉर्म देखते समय यह फ़ील्ड छिपा हुआ होता हैConsent2फ़ॉर्म देखते समय यह फ़ील्ड छिपा हुआ होता हैConsent3फ़ॉर्म देखते समय यह फ़ील्ड छिपा हुआ होता हैConsents