Program Consent This is a form to be filled out and signed by a parent / guardian of a youth attending a program at The MacPhee Centre for Creative LearningPlease enable JavaScript in your browser to complete this form.Parent or Guardian Name *FirstLastParent's or Guardian's PronounsThey/them, she/her, he/him, ze/hir, etc.Parent or Guardian Email *Parent or Guardian Phone Number *For casual contact. For example, if we need to be in touch on the day about a program, pick-up, drop-off, etc.Youth's Name *FirstLastYouth's PronounsThey/them, she/her, he/him, ze/hir, etc.Program *- Please select -Fall 2023OtherEmergency Contact InformationEmergency Contact Name *FirstLastEmergency Contact's Pronouns They/them, she/her, he/him, ze/hir, etc.Relationship to Youth *Emergency Contact Email *Emergency Contact Phone *Medical InformationDoes your youth have any additional concerns? *- Please select -YesNoDoes your youth need any extra support? This can be medical, social, physical, emotional, etc. Please let us know how best to help your youth. Please provide details of all concernsBe that medical, social, physical, emotional, or any thing else you might feel is relevantPlease provide details of medication that your child should carry during school tripsDoes your child have any known allergies? *- Please select -YesNoPlease provide details of all known allergiesDoes your child carry an Epi-Pen or similar device?YesNoDoes your child have any specific dietary requirements not covered above? *- Please select -YesNoPlease provide details of dietary requirementsVeganDairy freeVegetarianGluten freeOtherIf other, please specifyConsentConsent for the below listed items are for the year of 2023. You can withdraw consent for individuals by emailing us. I give permission for my youth to: *Take part in trips and other activities that take place outside of MacPheeOccasionally our facilitators want to take youth around Dartmouth. Some examples of previous activities include a mural walk, a photo walk, sketching in the park, etc. I give permission for use of photos, videos, and quotes of and belonging to my youth: *YesNoPhotography and video may be used on our website, social media channels, and promotional materials for the centre. Quotes/comments/thoughts made on evaluation forms, may be used on our website, social media channels, advertisements and promotional materials. Leaving the CentreHow does your youth get home at the end of the day?Please select one of the following: *My youth can leave the centre on their own (at the end of day, to get lunch, etc.)My youth must wait at the centre for me to receive themMy youth must wait at the centre for others to receive themIf other, please specifySpecifically, if you selected that another person (s) may receive your youth at end of day, please use this field to indicate such person (s). Signature of named parent or guardian *Clear SignatureSubmit
