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Action jeunesse
Registration
Mohiganech Social Club
For children from kindergarden to Grade 6
Cooking, sciences, arts, sports, traditional activities, outdoor output etc.
36 places maximum
Registration Form
Pedagogical Days
9:00 am to 4:00 pm
Information about the child
*
Indique un champ obligatoire
Child's name
*
Prénom
Nom
Specify the nation
*
Algonquin
Cree
Atikamekw
Hurons-Wendat
Malecite
Micmac
Montagnais
Mowhawk
Naskapi
Inuit
Abénaqui
Autre
Choisissez votre Nation dans le menu déroulant
Gender
*
Boy
Girl
Age
*
Teacher's name
*
Nom du professeur de votre enfant
School Level
*
Kindergarden
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
School's name
*
Sainte-Marie
Fatima
Saint-Sauveur
Sainte-Lucie
Saint-Joseph
Golden Valley
Papillon d'Or
Notre-Dame-du-Rosaire
St-Isidore
Health Insurance Card
*
Does the child have allergies?
*
Yes
No
I don't know
If the child have allergies, please specify them
*
Does the child have asthma?
*
Yes
No
I don't know
Does the child have diabetes?
*
Yes
No
I don't know
Does the chil has receive his tetanus shot?
*
Yes
No
I don't know
Does the child take medication?
*
Yes
No
I don't know
List of medication
*
Water safety
*
Swim alone
Swim with a life jacket
Does the child have a bike?
*
Yes
No
Pedagogical Days in wich the child will participate
*
Friday, November 22, 2019
Friday, February 7, 2020
Tuesday, March 3, 2020
Wednesday, March 4, 2020
Thursday, March 5, 2020
Tuesday, April 14, 2020
Friday, May 15, 2020
Information about the parents/guardians
Mother's (guardian) name
*
Prénom
Nom
Phone (home)
*
Phone (work)
*
Phone (emergency)
*
Address
*
Town
*
Postal Code
*
E-mail
*
Father's (guardian) name
*
Prénom
Nom
Phone
*
Address
*
Town
*
Postal Code
*
E-mail
*
Departure of the child
Is the child allowed to leave alone?
*
Yes
No
Person autorized to pick up the child
*
Prénom
Nom
[object Object]
Relation to the child
*
Person autorized to pick up the child
*
Prénom
Nom
Relation to the child
*
Responsabilities
As a parent, I take the responsibility of informing the Social Club facilitators and/or the community organizer, in person, by email, in writing or by telephone, of my child's absence for a day or delay so that facilitators can plan activities and transportation according to the number of children present.
Autorizations
I authorized the Val-d’Or Native Friendship Center employees to give to my child, if necessary, some medication without prescription.
*
Yes
No
In order to help the Mohiganech day camp to promote their services, I authorize the day camp employees to use the pictures or videos taken of my child during the day camp. These pictures or videos may be used to produce promotional tolls for the Val-d’Or Native Friendship Centre.
*
Yes
No
Veuillez cocher la case oui ou non
I accept that my child uses the Center’s transportation and taxi 24 for the Mohiganech day camp outhing activities.
*
Yes
No
I authorize the day camp animators to ensure that my child receves all necessary care. I also authorize them to transport my child by ambulance or other wise (at my expense) and have him admitted to a health facility. In case of emergency or if you can’t reach us, I authorize the doctor to provide all medical care required by his condition, including surgery, transfusion, injections anesthesia, hospitalization, etc….
*
Yes
No
The Val-d’Or Native Friendship Center can’t be liable for any loss, theft or accidents. Having read all the information, I authorized my child to participate at the day camp at the Native Friendship Center.
*
I agree
I desagree
Soumettre