Junior Youth Empowerment Program Registration Parents of new junior youth are required to attend an information session. Details are in the form below. Name of Participant * First Name Last Name Date of Birth * MM DD YYYY Home Address * Applicants are required to reside and/or attend school in the Edmonds neighbourhood of Burnaby School * Grade * Medical conditions, allergies * Is your child receiving one-on-one support at school? * Yes No Availability * Please select all days that apply: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Name of Parent/Guardian * First Name Last Name Phone * (###) ### #### Email * How did you hear about the program? * Image Release * Do you permit the use of photos and videos taken of the group’s activities that include your son/daughter to be used in the program’s promotional materials (eg. brochures, Instagram)? Yes No I hereby give permission for my son/daughter to attend this summer program. I understand that the Junior Youth Empowerment Program will endeavor to provide my son/daughter with a safe environment. In the case of personal injury, loss or damage I, or a third party, will not hold Junior Youth Empowerment Program, its agents or volunteers responsible. * Yes Information Session * Parents are required to attend a mandatory information session about the Junior Youth Program. Info sessions are offered every Wednesday at 5:30 PM. I will attend this Wednesday, 5:30-6:30 PM I will require another time for an information session (we will be in touch to confirm another date). Thank you for completing our registration. We will be in contact within a few days.