Youth Centre Membership Form*

YOUTH CENTRE
Youth Center membership will give your child access to our Drop In times at no additional cost! Drop In times will be mostly unstructured, with a variety of activities for your child to participate in, including our canteen (extra cost). Youth Centre membership are valid September 2023 – August 2024.

Memberships for Grades K-6 are:
$25 (military families) | $30 (others)

Memberships for Grades 7-12 are:
$15 (military families) | $20 (others)

If you wish, you have the option of paying a Drop In fee of $2 every time your youth attends, but the membership is the most cost efficient way to go!
Membership forms must be completed & dropped off at your first visit.

Membership fees can be paid, in person (debit/credit preferred), at the MFRC reception or over the phone (credit only) during regular business hours.
MFRC office hours are:
Monday-Friday
8 AM-4 PM

For any questions/concerns regarding this program, please contact:
Shannon Chapman, Youth Programs Coordinator
shannon.chapman@forces.gc.ca | shannonchapman@shilomfrc.ca
204-765-3000 ext. 4558

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1. Youth's Information:

Name: *

Grade: *

Date of Birth: *

Physical Address:

Home Phone number:

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2. Parent's Information:

Name of parent(s)/guardian(s): *

Primary Phone Number: *

Alternate Phone Number:

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3. Emergency Contact: (someone other than those listed above, in case they can't be reached)

Name: *

Primary Phone Number: *

Alternate Phone Number:

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4. Does your child have any allergies or specific medical or behavioural conditions the MFRC Staff should be aware of?

Yes

Please give details including the symptoms, severity of conditions, if your child carries an EpiPen or inhaler, and any other details that would be of assistance:

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5. Do you grant permission to the Shilo MFRC, its agents, and employees, the right to photograph you and/or your minor child registered for this program for use in any MFRC publication including print, web sites or other electronic form of social media.

Yes

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6. If your child is in grades Kindergarten-6, please indicate how your child will be getting home at the end of the program.

Walking or biking themselves home

Picked up, do NOT let walk home

If you selected "Picked up, do NOT let walk home", you will need to pick your child up from inside the MFRC. If you would like them to meet you outside, you will need to select walking or biking.

Should you need to change release information, please speak to one of our Youth Program Workers.

**Youth in grades 7-12 will be allowed to come and go from the centre at their own discretion. Children in Grades K-6 will be required to stay for the duration of the program unless other advised by the parent.

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7. Acknowledgment and Consent:
1. I acknowledge that it is my responsibility to advise the Youth Programs staff member of any medical or behavioural concerns of my child that may affect his/her participation in Youth Centre activities.
2. I understand that the Shilo MFRC is responsible for my child only during the time he/she is inside the Youth Centre.
3. I acknowledge that the staff of the Shilo MFRC will secure medical advice and services as deemed necessary for the health and safety of anyone participating in Shilo MFRC programs. The Shilo MFRC does not assume financial responsibility for any cost associated with seeking medical advice.
4. I acknowledge that my child is accountable to Youth Centre Rules. If my child does not abide by the rules, they may be subject to the Youth Centre behaviour management policy.

I agree with the above statements.

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8. Are you a releasing (within 12-16 months) or released military member or family member?

medically releasing military member

medically releasing family member

medically released military member

medically released family member

medically released military member (over 2 years post-release)

medically released family member (over 2 years post-release)

releasing military member

releasing family member

released military member

released family member

None of the above

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9. FOR OFFICE USE ONLY - DO NOT COMPLETE

Date:

Amount Paid:

Receipt #:

Staff Initials: