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Youth Leadership Consent Form

All forms must be completed by May 23, 2025. Thank you!

This is a leadership program designed to teach youth independence and confidence. As a result, we will always contact the youth first and only involve parents and guardians for emergencies or significant behaviour and disciplinary conversations. We appreciate your support in this matter.

Participant name (first and last name)

Participant address

Participant cell phone number

Participant email address

Has the participant previously completed a summer of the Youth Leadership Development Program (YLDP)? If so, what year?

Training date youth will be attending

June 21 and June 22 (year 1)

June 21 and June 22 (year 2)

June 7, 8, 20, 21, 23, July 16 (year 3)

Medical Information

If medication is to be administered during program time, you must complete a medical administration form.

Camp staff can only help administer oral medications and assist with epi-pens. They can't administer any other medications.

Please share information regarding your youth's needs or abilities to assist our leaders in making this volunteer experience a great one.

How will your youth's disability/special needs effect participation in our program. Please provide some strategies to assist our staff in providing a positive program experience.

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Main Parent/Guardian Contact Information

In the event of an emergency please list your phone numbers and contact information so we can contact you if needed.

Main parent/guardian name

Parent/guardian home telephone number

Parent/guardians work or cell phone number

Parent/guardians email address

Emergency Contact Information

In the case where we cannot reach the main contact person, please indicate another contact that we can contact.

Emergency contact name

Emergency contact telephone

Emergency contact email address

Second Emergency contact name

Second Emergency contact telephone

Second Emergency contact email address

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Emergency Medical Treatment

In the event of an accident or illness involving my youth while attending and volunteering in programs I hereby authorize, if I am not immediately available, the administration of any medical procedure deemed necessary by the youth's physician, or any other physician selected by the program staff. I also give my permission for my youth to be transported to the physician's office or the hospital Emergency Department with no liability on the drivers's part. An ambulance may be called to transport my youth to the hospital if required; billing for the ambulance will be forwarded to the master contact specified on the registration form.

Consent

Yes

Excursions off the Property

The camp your youth is volunteering at may be taken away from the program premises by the staff, by means of any manner of public or private transportation or otherwise, for walks, picnics or outings of any kind as may, from time to time, be scheduled as part of the program. Staff members are not allowed to drive participants for any reason. Routine activities for camps may include walking to and from the park, swimming in a lifeguarded pool and visiting the splash pad at Waterloo Park. Please note that you will be required to sign an informed consent form listing the details if there are more excursions off the property than what is listed.

Consent

Yes

Authorization for publicity: The above mentioned participant may appear in advertising/publicity arranged by the City of Waterloo. through various media outlets including newspaper, radio, tv, slide presentations and printed or electronic publications.

Yes

Parent/Guardian Consent

As the participants Parent or Guardian, I have read and understood the specific program details outlined above and give permission for participation.

Make sure to read our information package (PDF) - it has everything you need to know about attending camp.

Parent/Guardian Consent

Yes

Under the authority of the Municipality Act, 2001, S.O., Personal Information, including Personal Health Information, will be collected for the administration of the camp program. As part of the camp program, participants' health information collected will to ensure safe and supportive programming for each participant. If you have any questions regarding the collection and handling of this personal information, please contact Community Leisure Programming at camp@waterloo.ca, 519-886-1177 x 27280 or 100 Regina Street South, Waterloo, Ontario, N2J 4A8.

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