LIT Intake Form

Participant name(Required)

First Last

Birthdate(Required)

Participants in LIT must be between 14 and 17 years old and have completed Grade 8 before training.

Participant email address(Required)

Email address Confirm email

Parent/Guardian info

Please include your parent or guardian's information in this section. They will need to electronically sign off on the application before submitting.

Parent/Guardian name(Required)

First Last

Address(Required)

Street address City Province Postal code

Parent/Guardian email(Required)

Phone number(Required)

Alternate phone number

Work/daytime phone or additional guardian contact

Participant application

Please describe why you want to participate in the Leaders in Training program(Required)

Please describe any previous volunteering, work-related experience or applicable special interests.(Required)

Please choose all the outcomes you'd like to experience from the program.

I want to build up my overall leadership skills

I want to meet new people

I want to gain experience for future employers

I want to use this experience to help me get into post-secondary

Other, please describe below:

Other outcomes

Please use this space to describe other outcomes you're hoping to take away from the experience.

Participant t-shirt size(Required)

T-shirt size comment(Required)

Summer availability

Please indicate your summer availability (minimum 2 weeks) below. Leadership Experience during the summer will be at either kids camps or Summer in the Park. All efforts will be made to accommodate your top two choices. Programs run from July 6 to August 21.

July

July 6-10

July 13-17

July 20-24

July 27-30

August

August 4-7

August 10-14

August 17-21

Preferred weeks

Please indicate your top 2 choices for placement weeks, if your availability indicates more than 2 weeks.

Training confirmation(Required)

Yes, I can attend the July 2 and 3 training sessions

Medical information

Please list any allergies, medication or other information staff should be aware of.

Emergency contact(Required)

My emergency contact is the listed parent/guardian

My emergency contact is someone else

Emergency contact name(Required)

Emergency contact relationship(Required)

Emergency contact phone number(Required)

Emergency contact secondary phone number

Waiver for activities

This waiver must be completed by a parent and or guardian before attending any programs. Please read carefully.

I give permission for my child:(Required)

to participate in the City of Beaumont Leaders In Training program and the Leadership Experience program. I understand the nature of the activity, the varying supervision provided and that there are inherent risks associated with this activity and that my child could sustain personal injury through participation in this activity, and I am hereby accepting to take that risk on behalf of my child. I hereby 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 taking part in this activity, but limited to taking part in this activity.

Parent or guardian's electronic signature(Required)

Please type your full name

Date signed(Required)

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 process your application and assess your eligibility for the program. Information will be kept confidential and shared only with individuals involved in the review and administration of the program. If you have questions about the collection or use of your personal information, please contact the Privacy Officer at 780-929-8782.

Leaders in Training Participant Intake Form and Waiver

Parent/Guardian info

Participant application

Summer availability

Medical information

Waiver for activities

Non-emergency concerns

Program registration

LIT Intake Form

Leaders in Training Participant Intake Form and Waiver

Parent/Guardian info

Participant application

Summer availability

Medical information

Waiver for activities