CNIB Toronto Application

CNIB Toronto Application

CNIB Toronto, 1929 Bayview Avenue, is pleased to offer summer programs for children and youth with vision loss.

Please check the appropriate program:

Yes/No Summer Program for Children– July 7-11, 2014

Yes/No College and University Preparation Program – July 28-Aug. 1, 2014

Yes/No Teens Involved in Employment and Sports – July 2-24, 2014

Yes/No Steps to Independence – August 11-15, 2014

Applicant Contact Information
Name:

Date of Birth:

Age:

M/F

Street Address:

City:

Province:

Postal Code:

Phone:

Email Address:

Emergency Contact Information

Name:

Relationship:

Phone Number:

Applicant Health Information

Please list any health concerns:

Please list any medications and provide instructions:

Please provide information about vision:

Please provide information about hearing:

Please provide information about any physical disabilities that may need to be accommodated:

Please list allergies:

Please list dietary restrictions:

Transportation

Please indicate how your child will be transported to CNIB for the session:

Parent to provide transportation.

Drop-off contact name:

Drop-off time:

Phone Number:

Alternate Phone Number:

Other

Pick-up contact name:

Pick-up time:

Phone Number:

Alternate Phone Number:

The program starts at 9 a.m. and ends at 3 p.m. Drop-off should be arranged for 8:50 a.m. and pick-up by 3:10 p.m.

Child requires transportation.

In order to help cover the costs of the program, CNIB will be re-introducing a registration fee of $25/child. In addition, door-to-door transportation will be available for families who require additional support. The fee for this service will be $25/child. CNIB recognizes the additional fees may be a barrier. If this is the case, please contact, Sue Marsh-Woods to discuss financial assistance. She can be reached at 416-486-2500 ext. 8280.

CNIB provides accommodations for people living with vision loss. If your child required additional accommodations due to other special needs, please make arrangements for an assistant to accompany the child to ensure full participation.

CNIB Waiver

I, , allow my son/daughter, , to participate in CNIB Toronto’s summer programming.

I agree to indemnify and save harmless the CNIB, its organizers, agents, officials, servants and representatives from all liability and, without limiting the generality of forgoing, from all claims, loss damage, injury, liability, costs and expenses of whatsoever kind or nature (including legal fees) howsoever the same may be caused resulting directly or indirectly from the above mentioned event provided to me by the CNIB by its organizers, agents, officials, servants and representatives, notwithstanding that the same may have been contributed to or occasioned by their negligence.

Promotional Consent Form for Individuals

To acquire new images to help promote our charitable aims and objectives and services we provide to our clients and community.

I understand that I am providing promotional material to CNIB, a not for profit charitable organization.

I understand in giving my time to CNIB that I will receive no monetary compensation for participation in any promotional activities.

I understand this agreement is valid for a three-year period commencing on the date as stated above.

I give consent for information, photographic images and/or video and sound recordings (‘promotional material’) to be used by CNIB.

I give consent for all or part of the material to appear in any of the wide variety of formats and media now available and that may be available in the future, including but not limited to print, broadcast, CD-ROM and electronic/online media.

I give consent to the promotional material being shown to appropriate professional staff and the general public.

I understand that materials may be repurposed by CNIB over the length of the agreement.

I understand that I may withdraw my consent at any time by contacting the person below.

I agree with the above statement. I confirm my consent by signing below.

Signature of ParentDate

Code of Conduct

Participants must respect the rights and property of others.

Property and staff at locations where field trips are held must be respected.

Participants must act co-operatively and follow the instructions of the program staff and leaders.

Appropriate and acceptable language is expected.

Participants must arrive on time (9 a.m.). Failure to arrive by 9:15 a.m. without notice may forfeit planned activities/field trips.

Please note: If the participant fails to adhere to the code, the participant will be removed from the program.

Name of Participant Signature of Parent