Optimist Club Bowling 2023

I would like to register the participant during the following weeks: *

*Registration limits have has been reached for the weeks of July 11, July 18, Aug 22 and Aug 29th. Any future submissions for these weeks will be added to our waitlist.

Participant Information

Name *

First

Last

Layout

Birthdate *

Age

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Layout

Participant Email

Health Card # *

Parent/Guardian Information

Layout

Parent/Guardian Name(s) *

Relationship to Participant *

Layout

Parent/Guardian Email *

Daytime Phone *

Cell Phone

How did you hear about Bowling with the Optimist Club?

Emergency Contact

Separate Household - to be contacted in case parent/guardian cannot be reached.

Name *

First

Last

Layout

Relation to Youth

Daytime Phone *

Cell Phone

WAIVERS AND CONDITIONS OF ENROLMENT:

1. Empower Simcoe reserves the right to dismiss a participant who, in our opinion is a hazard to the safety and rights of others, or who appears to have rejected the reasonable controls of the program. Failure to disclose concerns at time of registration could result in dismissal.

2. The parent/guardian(s) of the above-named participant, release Empower Simcoe, its staff members and Optimist Club volunteers from any loss, personal injury, accident, misfortune or damage to the above-named or his/her property, with the
understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named participant.

3. In case of medical emergency, the parent/guardian(s) of the above-named participant understands that every effort will be made to contact them. In the event that the parent/guardian cannot be reached, I /we give permission to the Empower Simcoe staff member and the attending doctor to secure medical treatment for and/ or hospitalize the above-named participant.

PHOTOGRAPHY/MEDIA CONSENT AND RELEASE

Empower Simcoe sometimes asks people to let us use their photo, video or audio to promote Empower Simcoe’s work or
tell others what we do.

I understand that a photo, video or social media posting may appear in public promotional material for many years.
Empower Simcoe may, at any time, reproduce, publish and/or republish the video, photograph(s) or audio for
any communication, advertising and/or promotional purposes, including the posting of the video or any portion thereof
on the agency’s websites.

This consent will remain valid for one year from the date signed.

Authorizing person(s) may cancel or change the above authorization in writing at any time prior to the expiry date, unless
action has already been taken on the basis of the authorization.

I hereby give my/our permission and consent to Empower Simcoe to collect and use Photography and/or Video of my child to promote and advertise the programs & services of Empower Simcoe.

I hereby give my/our permission and consent to Empower Simcoe to collect and use Photography and/or Video of my child to promote and advertise the programs & services of Empower Simcoe, including: *

I understand that if I am not able to attend on a date registered, I will notify the Program Associate, Laura McArthur, via email at lmcarthur@empowersimcoe.ca so that another child/youth on the waitlist may participate.

I have read and hereby agree with the waivers and conditions of enrolment.

Parent / Guardian Signature *

Optimist Bowling 2023

Bowling Registration Form

Participant Information

Parent/Guardian Information

Emergency Contact

WAIVERS AND CONDITIONS OF ENROLMENT:

PHOTOGRAPHY/MEDIA CONSENT AND RELEASE

QUICK LINKS