Royal Botanical Gardens

YESProgram Registration Form

Applicants must include a letter of recommendation from

a teacher, guidance counsellor or other non-related adult.

NAME / AGE
ADDRESS / GENDER
CITY / POSTAL CODE
Parent/Guardian NAME
HOME PHONE / OTHER Phone
Parent/Guardian NAME
HOME PHONE / OTHER Phone
E-MAIL
DO YOU A HAVE ANY MEDICAL CONDITIONS? / ❑Yes ❑No
DETAILS
ARE YOU ON ANY MEDICATION? / ❑Yes ❑No
DETAILS
DIETARY CONCERNS/CONDITIONS (I.E. ALLERGIES, DIETARY RESTRICTIONS)
Have you attended Royal Botanical Gardens’ programs before? / ❑Yes ❑No
If yes: which programs?
Are you willing to commit to the entire program: October 2016 – June 2017? / ❑Yes ❑No
What would you say is your favourite aspect of your local environment?Attach additional sheets as necessary.
have you considered what you will pursue in post secondary? if so, what and how can this program help?
Why do you want to be part of this program?
WHAT UNIQUE PERSONAL CHARACTERISTICS AND SKILLS WOULD MAKE YOU AN ASSET TO THIS PROGRAM?
Legal Guardian Consent
IF AT ANY TIME EMERGENCY MEDICAL TREATMENT IS NECESSARY FOR MY CHILD, I GIVE MY CONSENT FOR TREATMENT TO BE GIVEN. EVERY EFFORT WILL BE MADE TO CONTACT PARENT/GUARDIANS(S) AND OR EMERGENCY CONTACTS.
❑Yes ❑No
AUTHORIZATION RESTRICTIONS
EMERGENCY CONTACTS (IF GUARDIANS CANNOT BE REACHED)
NAME / PHONE
RELATIONSHIP
NAME / PHONE
RELATIONSHIP
COMMENTS
CONSENT FORM
I/we, the undersigned hereby acknowledge that certain activities include excursions by foot and/or canoe. Our programs include outdoor hikes on our nature trails in hilly terrain, canoeing, crafts, and active games, as well as short audio-video components to reinforce concepts and themes. I/we hereby warrant that my/our child is physically and psychologically fit to participate in such activities and understand that the choice to participate brings with it the assumption of those risks and results which are part of these activities. I/we agree that Royal Botanical Gardens (RBG), its trustees, officers, directors, employees, agents and independent contractors shall, in no event, be liable for any injury to my/our child’s person or loss or damage to my/our child’s personal property of any kind, including direct, indirect, special, exemplary, consequential, multiple, punitive or other damages, arising from or in any way resulting from my/our child’s participation in these activities. I/we understand that video production and/or photography may be conducted during the program. I/we grant full and irrevocable consent to RBG and those acting under its permission or upon its authority, to reproduce, publish, copyright, or otherwise use my/our child’s photographic likeness. No personal identifying information (i.e. name/address) would be associated with the use of the image.
PARENT/GUARDIAN SIGNATURE
DATE

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