YCLC REGISTRATION FORM

Most questions on the form are pretty straightforward - and are standard questions asked
when a youth or adult REGISTERS for an outdoor program. All of the questions in GREEN
require an answer in order for the form to be sent (i.e. if you don't fill them in you will receive
a prompt to do so). The two questions in black require an answer only if they apply to you.
If not, don't answer them. Questions on disability, health status, special diets and medication
 may require more communication than filling in a form - on your part or ours.



PROGRAM WAIVER

Please note that it is also standard procedure to sign a WAIVER when sending
a youth to such an event or when attending such an event yourself. The WAIVER
acknowledges that participants have choice over participation in any aspect of
the program without exception, and that they also accept responsibility for injury,
however incurred. Close to the time of your program we will e-mail you a copy of
the specifc WAIVER for your event. This is standard for every activity of this type
and certainly not uniue to our program. It protects you and the organizers and the
providers of insurance in the case of disputes over liability.

 No youth or adult can be admitted without a signed WAIVER.

Which YCLC event do you wish to attend:

Name: First:    Last:

E-mail:

Address:

City: Prov: Postal Code:

Area and Phone#:

Age:

Gender: M F

Languages Spoken:(list in order of frequency spoken)

Are you a registering as a:

Contact name or Parent name (in case of emergency):

 First and Last Name:    

 Area code and Phone #:

Will you need help with payment? Yes No (We will get back to you if you need help)

We work with youth organizations such as Big Sisters Big Brothers to make
this program available to those who may not be able to come otherwise. If you
wish to assist a youth or adult mentor who needs financial help to attend, please
 enter the amount here (optional):


Can you provide car-pool transportation to get youth to/from the event?
(Mentors cannot provide transportation to youth or other volunteers as they will be required to attend a training
 session before the event.)

Yes No Maybe

Are you bringing your own food because of diet restrictions? Yes No

 Do you have any limitations on physical activity?
 If you do, please describe (if none, write no):


Do you require supervised medication administration?
Yes No

List any drug sensitivites and/or food allergies (optional - leave blank if you have none) :

Why do you want to attend. (Parents, please have your son or daughter complete):


<>Name of person or organization who told you about YCLC?




When you press the SEND FORM button it will take you to a WELCOME page, which will
also tell you what to do next. If for any reason you press SEND FORM and then fail to
reach the WELCOME PAGE, please call us at 819-827-0561 right away and we will help
you through the process. We have found that some older computers fail to perform this function.