Membership Form

Youth information

Youth must be between 12 and 17 years of age. Submitting this form indicates consent for the youth to participate in Chantal Bérubé Youth Centre (CBYC) programs/activities/fundraisers.

Name(Required)

First Middle Last

School

Birthdate(Required)

Youth email

Enter email Confirm email

Youth mobile phone

Youth social media

Home phone(Required)

Address(Required)

Street address City Province Postal code

Medical or behavioural concerns

Please use this space to indicate if the staff should be aware of anything related to your youth.

Parent/Guardian information

Name of parent or guardian(Required)

First Last

Email(Required)

Enter email Confirm email

Work or mobile phone(Required)

Please add another contact besides your home phone (listed above).

Home addresss(Required)

Same as above

Different address from youth

Guardian home address(Required)

Street address City Province Postal code

I give my consent to be:

added to the City of Beaumont FCSS e-newsletter

contacted to participate in upcoming programs/activities/fundraisers

Emergency contact

In the event of an emergency and we cannot reach the parent/guardian listed above, we should contact:

Emergency contact name(Required)

First Last

Emergency contact phone number(Required)

Relationship to youth(Required)

Waivers and liability

I, or my child, may participate in the activities, programs, and fundraisers selected below, as well as any related or activities of similar nature, whether or not specifically listed (collectively, the “Activities”) :

Activities at the Chantal Bérubé Youth Centre

Games (i.e., nerf gun toys, foosball, ping pong, air hockey, etc.)

Cooking Club

Arts and crafts

Mental health, life skills and other skill building workshops

All other CBYC programming

Activities in Beaumont, Edmonton and/or surrounding areas

Movie night

Bowling

Activate (adventure sporting centre)

Paintball

Sports and activities at the Beaumont Sport and Recreation Centre

Outdoor field sports (i.e. soccer, hockey, basketball, tennis, etc.)

Drop-in sports at the Beaumont Sports and Recreation Centre (i.e. swimming, team sports, rock climbing, racket sports, etc.)

Or only the following:

Specifically allowed BSRC activities

Please indicate which Activities you give consent for:

Activity and risk waiver:(Required)

I understand the nature of the Activities selected, the limited supervision provided and that there are inherent risks associated with the Activities, and that I or my child(ren) could sustain the following through participation in the Activities:

• Physical and mental injury, illness or death arising from physical exertion, contact with the other participants, use of equipment, or exposure to environmental hazards.
• Damage to or loss of personal propety; or
• Other injuries or damages arising from the actions or negligence of myself, my child or other participants, or the actions or negligence of the City or its employees or other representatives.

I am hereby freely and voluntarily accepting to take the associated risk on and agree to save harmless and indemnify the City of Beaumont, its organizers, agents or employees against claims, expenses and demands in respect to injury or death arising out of myself or my child(ren) taking part in the Activities.

Transportation waiver:(Required)

Where the City of Beaumont (the “City”) offers transportation as part of the Activities, I consent for myself or my child to be transported by the City in connection with the Activities selected above. I acknowledge that transportation involves inherent risks, including the risk of injury, loss, or death, and I assume all liability for any injury that may happen as a result of the transport. I further agree to hold harmless the City, its officers, employees, members, volunteers, or anyone acting on its behalf, for injury resulting or related to such transportation.

Medical waiver (if under 18):(Required)

I hereby authorize Staff/Volunteers of the Centre Chantal Bérubé Community Youth Centre to have my child transported to the hospital for any emergency treatment that may appear necessary in the event that I cannot be contacted immediately. I further consent to pay any medical expenses incurred that are not covered by my health insurance plan.

Photo consent waiver

I hereby grant permission to the City of Beaumont, its organizers, agents or employees, full and free use of video, recording, or photographs containing my or my child’s image/likeness. I understand that these images may be used for promotional purposes, news, research, and/or educational purposes. I hereby release, discharge, and hold harmless the City of Beaumont, its organizers, agents or employees from any and all claims, demands, or causes or action that I may hereafter have by reason of anything contained in the photographs or video.

Electronic signature(Required)

Please type your first name, middle initial and last name.

The personal information collected is authorized under Section 4(c) of the Protection of Privacy Act and is managed in accordance with the Act. It will be used to administer membership, provide program services, respond to emergencies, and communicate with members and their parents/guardians. As mandated reporters this information may be shared with police or Children’s Services. Information will not be disclosed to any other third parties except as authorized by law. It may be entered into an automated system to generate content or make decisions, recommendations or predictions. If you have questions about the collection or use of your personal information, please contact the Privacy Officer at 780-929-8782.

Chantal Bérubé Youth Centre Membership

Youth information

Parent/Guardian information

Emergency contact

Waivers and liability

Non-emergency concerns

Program registration

Membership Form

Chantal Bérubé Youth Centre Membership

Youth information

Parent/Guardian information

Emergency contact

Waivers and liability