Name of Parent/Guardian *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Number *

(###)

###

####

Name of Junior Youth *

First Name

Last Name

Currently in Grade: *

Grade 6

Grade 7

Languages Spoken *

English

Chinese

French

Other

Media Release *

Do you permit the use of photos and videos taken of the group’s activities that include your child to be used by RYEC and SD38 for promotional materials (eg. brochures, website, etc.)?

Yes, I give permission.

No, I do not give permission.

After Program Pick-up Permission

Please indicate whether a parent/guardian will be picking your child up after the program each week, or if they have permission to make their own way home.

A parent/guardian will pick my child up after the program each week.

I give my child permission to make their own way home after the program each week.

I hereby give permission for my child to attend this after-school program. I understand that Richmond Youth Education Center will endeavour to provide my child with a safe environment. In the case of personal injury, loss or damage I, or a third party, will not hold Richmond Youth Education Centre, its agents or volunteers responsible. *

Yes, I give permission.