YAAACE Program Registration

DISCLAIMER

YAAACE is a non-profit organization that heavily relies on various grants from the Provincial and Federal Government, as well as other organizations. The following information requested below will be used for internal reporting measures to help determine the need in our community and obtain additional funding and resources to subsidize the cost for all of our participants with the hopes of making all future programs free of cost. We ask that you answer these questions as accurately as possible.

Please note that all data provided on this form and in research surveys may be shared and collected solely in order to evaluate YAAACE programs and their impact on the community that we serve. You may be contacted for follow up research for a period of up to 2 years following the completion of any of the organizations programs.

PARTICIPANT INFORMATION

STUDENT NAME (do not add brackets or include nicknames)

First NameMiddle NameLast Name

Has this student registered for a YAAACE program in the last 6 months?

Sex

Preferred Pronouns

If so, please select which programs this student has previously participated or are currently participating in. (Select all that apply)

Date of Birth

Date

Current Grade

SELECT GRADE THE CHILD WILL COMPLETE IN JUNE

Current School

Name of School

School NameSchool Board

Student OEN

Do not include dashes. This number can be found on the student report card.

Does this student play on any sport Rep teams?

Other

Shirt Size

Required for summer camp and sports programs only

Has the contact information for the student changed since last registering?

Home Address

Street Address

City

Postal Code

Student Email (optional)

example@gmail.com

Student Cell Phone # (optional)

Format: (000) 000-0000.

Student Instagram Handle (optional)

Allergies/Medical Information (Answer ONLY if applicable to your child. If none, leave blank)

Rows	Brief Description
Allergies to food/ medicine
Does the child carry an epi-pen or inhaler
Other medical conditions

BILLING AND EMERGENCY CONTACT INFORMATION

Parent/Guardian

First NameLast Name

Parent/Guardian Phone Number

Format: (000) 000-0000.

Email (to be used for billing and program correspondence)

Confirmation EmailALL CORRESPONDENCE AND INVOICES WILL BE SENT TO THIS EMAIL ADDRESS.

Is this person also the Primary Contact?

Primary Contact Name

First NameLast Name

Relation to Student

Phone Number for Primary

Format: (000) 000-0000.

Email for Primary

example@gmail.com

SECONDARY CONTACT INFORMATION

This person will be contacted if we are unable to reach the parent/guardian/primary contact.

Secondary Contact Name

First NameLast Name

Relation to Student

Phone Number for Secondary

Format: (000) 000-0000.

Email for Secondary

example@gmail.com

END OF DAY SIGN OUT AUTHORIZATION

I allow my child to leave the premises on their own at the end of the day. I hereby inform YAAACE that my child has my permission to walk home after the end of programming without adult supervision. I acknowledge YAAACE will no longer be responsible for my child after they have left school property.

In addition to the emergency contacts named above, I hereby provide authorization to the following additionally named persons (over the age of 16) to pick up/sign out my child at the end of day. I understand that they may be asked to show ID. Their name(s) and contact number(s) are as follows:

ADDITIONAL INFORMATION

Ethnicity

Approximate Annual Household Income

Rows	Less than 40k	Between 40-60k	Between 50-80k	Over 80k
Single Income Household
Dual Income Household

Have you or a family member had contact with the Criminal Justice System?

How did you hear about YAAACE (Please select all that apply)

RELEASE AND ACKNOWLEDGEMENT

I, {parentguardian169}, acknowledge that the registration and demographic data provided within this form will be used for research purposes only. I hereby provide my consent to allow the organization to use this information.

I, {parentguardian169}, acknowledge that photographs and video may be taken of my child while participating in YAAACE programming and posted to social media, news releases, publications or archived for future use. I further acknowledge that by providing the instagram handle of my child, they may be tagged by the organization in posts for engagement and relationship-building purposes only, and that I have the option to opt out or can provide this information at any time by contacting the organization and that it will not monitored or shared by staff. I hereby provide my consent to allow the organization to use those images solely for their not-for-profit purposes and waive the right to any and all compensation stemming from the use of these materials.

I understand that non-payment of program fees (where applicable) will result in my child losing their spot in the program.

I, {parentguardian169}, continue to acknowledge that all collected data will be used for research purposes only and any photographs/videos taken of my child while participating in such programming may be used in present or future publications or social media posts. Furthermore, I understand that non-payment of program fees (where applicable) will result in my child losing their spot in the program.

YAAACE PROGRAMS

Summer Institute$350.00 CAD

(Grades 3-7 ONLY) Six-week summer camp program running July 6th to August 14th.

Please pick one of the following options:

Gr 9/10 Summer Math CreditFree

(Grades 8-9 ONLY) Ministry-accredited summer math course for students going in to Grade 9 and 10. LIMITED SPOTS AVAILABLE

Community Days (SUNDAY Drop In)Free

(Grades 6-12 ONLY) Developmental basketball and character education for the Jane and Finch Community. Free to students in the Humber River-Black Creek catchment. 1 hr of skills training and 30-45 minutes of scrimmaging,

Total $0.00 CAD

Individual invoices (where applicable) will be emailed for each program once registration is complete.