Youth Information
Birthday *
Parent/Guardian Contact
Name of Parent/Guardian *
Name of Parent/Guardian
Best Phone Number for Parent/Guardian *
Best Phone Number for Parent/Guardian
Emergency Contact if Parent/Guardian is unavailable
Name of Emergency Contact
Name of Emergency Contact
Best Phone Number for Emergency Contact
Best Phone Number for Emergency Contact
Medical Info
Does the participant have any special physical, emotional or behavioural, or dietary needs which may require special attention? If yes, please describe in detail, in areas below.
Event Release
As parent/guardian, I hereby authorize my youth to participant in below stated event hosted by The Meeting Place, Nanaimo and release The Meeting Place, its staff and volunteers from liability and responsibility for any injury or illness that my child may sustain during the event(s) or in transit to and from the event(s). As parent/guardian, I authorize my youth to be transported by staff and volunteers of The Meeting Place, or arrange for transport to the NEAREST SUITABLE MEDICAL OR HOSPITAL FACILITY in the event of an emergency situation that is not treatable at the scene. In such an emergency, I hereby authorize a staff of The Meeting Place, as my agent, to consent to any medical/dental diagnosis and treatment advised and supervised by a physician, surgeon or dentist (as appropriate). I expect to be contacted as soon as possible. In the event that medical assistance cannot be reached, I hereby give permission for first aid intervention to be administered by personnel from the group. On occasion, the leaders might as determine that a participant may require Tylenol.
Parent/Guardian Name *
Parent/Guardian Name
The City Youth Event
Date Submitted *
Date Submitted
Checkbox *
By checking the box below, I am confirming that I, above stated parent/guardian, have read and consent to above stated release for above stated event of The City Youth.