SOLE BOYS
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Volunteer "Man-tor"
Winter Program Registration Form
Location: Vancouver MEC!
Simply fill in the form below to secure your
spot
at our Vancouver location.
*
Indicates required field
Which Program?
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Vancouver MEC
What School does the Participant attend?
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Participant's Name!
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First
Last
Particpant's Date of Birth
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What grade is she in?
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3
4
5
6
7
other
Sole Girl's Carecard Number
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Parent/Guardian's name
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First
Last
Parent/Guardian's Email Address
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Home Phone Number
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Cell Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Emergency Contact Name
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First
Last
Emergency Contact Phone Number
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Emergency Contact's relationship to the participant
*
Medical information, please check if the participant has a history of any of the following: (Please check all that apply)
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Heart Disease or Heart Problems
Hypertension or High Blood Pressure
Stroke
Diabetes or Abnormal Blood Sugar Test
Epilepsy or Seizures
Abnormal Chest X-Ray
Orthopaedic or Muscular Problems
Participant lives with someone who smokes
Participant has a close relative (mother, father, sibling) with a history of Heart Disease
Asthma or Allergies (if yes, please tell us more below)
Particpant uses an inhaler
Participant uses an epipen
no history of medical problems
other (please indicate below)
Other Conditions, health issues or perscription drugs (please list below):
*
Please check the following to confirm you agree.
Purpose of the program: The purpose of the program is to empower your daughter with confidence, increase your daughter’s activity/fitness level and self-esteem while at the same time teaching life skills that will be beneficial to her as she enters adolescence.
*
yes
Pre- and Post Session Evaluation: With your permission, your daughter may complete a confidential pre and post survey at the beginning of the program and at its end. The survey measures student attitudes towards school, family, self and peers. The purpose of this survey is to measure any group attitudinal changes that may (or may not) occur because of participation in this program. You are asked to get involved in your daughter’s experiences, please advise Ashley (facilitator) if there are any changes in your daughter’s behavior during the program.
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yes
Release (Injuries): Serious health risks are rare. Physical reactions to exercise may include heat related illnesses, abnormal heartbeats and blood pressure and in rare instances heart attacks. While we take all reasonable precautions, we can make no guarantees regarding these risks. You (the parent or legal guardian) agree not to hold Ashley Wiles or Sole Girls liable for any injury or damages due to participation in the Sole Girls program.
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yes
Release (Photo): During the program, we occasionally take photos and videos of the girls for use in our future programs and to recap the event for the girls at the end of the program. With your permission given herein, we may also use these photos and videos for future brochures, publications, or in other ways to promote the program.
*
yes
Authorization: I, the parent and or guardian, have read this form and I am aware that by signing it I am waiving certain legal rights. I understand there are inherent risks associated with physical activity. To the best of my knowledge there are no contradictions to my daughter’s participation in the Sole Girls program. By my signature below, I give permission for my daughter to participate in this program, including the evaluation testing, for any pictures or videos in while she appears to be used as described above and for the information specified above. Cancelation Policy: 2 weeks prior to the beginning of the course 10% fee is charged. Less than 2 weeks prior to the course a 20% fee is charged. No refund will be issued once the course has begun.
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yes
I, The Parent and/or Guardian AGREE TO THE TERMS LISTED ABOVE BY WRITING MY NAME BELOW
*
First
Last
Signed, Today's Date!
*
Submit
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