Program Registration Form

Thank you for taking the time to complete this form. These questions are important for funding purposes.
All information collected is kept completely confidential.

Participant Information

Participant Name

This address will receive a confirmation email

Phone

Address

Date of Birth

Gender

Male Female Other

Allergies

Do you identify as any of the following: Born Outside of Canada LGBTQ+ Indigenous Pregnant Postnatal (up to 18 months)

If pregnant, due date

Are you at risk of any of the following Homelessness Substance Abuse Family Violence Social Isolation

Is your total income less than

$20,366 $25,253 $31,168 $37,843 $42,920 $48,408 $53,894 Prefer no to answer

Household Information

Member 1

Member 1 - Full Name

Member 1 - Date of Birth

Member 1 - Relationship to Participant

Member 1 - Allergies

Member 2

Member 2 - Full Name

Member 2 - Date of Birth

Member 2 - Relationship to Participant

Member 2 - Allergies

Member 3

Member 3 - Full Name

Member 3 - Date of Birth

Member 3 - Relationship to Partipant

Member 3 - Allergies

Member 4

Member 4 - Full Name

Member 4 - Date of Birth

Member 4 - Relationship to Participant

Member 4 - Allergies

Member 5

Member 5 - Full Name

Member 5 - Date of Birth

Member 5 - Relationship to Participant

Member 5 - Allergies

Participant agreement

Please read the following before submitting. Staff will review these with you at check-in and provide a printed copy on request.

📋

OKC policies. I have read, understand, and agree to the OKC policies. Staff will review the policies with the participant and provide a copy if requested.

📷

Photo & video release. I agree to the right to reproduce, use, exhibit, display, broadcast, and distribute photographed images and videos taken of me (or my child) for use in connection with the activities and promotion of OKC — including print, broadcast, videotape, CD-ROM, and electronic/online media.

👨‍👧

Supervision of children. I am responsible for the children in my care while at OKC programs.

I have read and agree to the OKC policies, photo/video release, and supervision responsibilities outlined above.

Program Registration Form

Description

Please Fix the Following