Weekend Room 13 Studio - Application Form

Ages 6 – 12 years

* Free with HCC Membership

Application Number: ______Winter Session: Saturdays or Sundays: Jan.16th–Mar.13, 2016

Weekend Room 13
Dates/Hours of Operation:
Please select which day you would like your child to attend. Children can only participate in one day:
______Saturdays (Jan. 16th – Mar.12th)1:00 – 3:00 pm (Ages: 9-13yrs)
______Sundays (Jan.17th– Mar. 13th)1:00 –
3:00 pm (Ages: 6-8yrs)
Please Note: Space is limited to12 children per day.
Families will be contacted to confirm placement.
What does Room 13 do?
Room 13 is an art studio for kids (ages 6-12 years) where you learn different kinds of art with the help of Artists! You will experiment with painting, drawing, printmaking, photography, sculpture, video & more! / *Free with HCC Membership
Placement Priority will be given to:
1) Families living in HCC catchment area (bound by Strachan Avenue, Yonge Street, Front Street and Lake Ontario)
**Proof of HCC Membership & Local Residence (eg. Drivers license, utility bill) is required at the time of registration.
2) Children who have not previously participated in Room 13
Has your child participated in Room 13?
Yes ______No ______
If so, how many sessions?
Child/Ward’s Name: / Date of Birth(dd/mm/yyyy):
Mailing Address: / Postal Code:
Parent/Guardian #1 Names: / Parent/Guardian #2 Names:
Home Phone: / Home Phone:
Work/Cell Phone: / Work/Cell Phone:
Email Address: / Email Address:
Emergency Care(Please provide us with names and numbers of alternate emergency contacts)
Emergency Contact: / Emergency Contact:
Emergency Phone: / Emergency Phone:
Relationship to Child: / Relationship to Child:
Name of Child’s Physician: / Physician’s Phone:
Medication currently taken by Child:
Allergies/dietary restrictions:
Child Release Authorization: Person(s) on this list will be permitted to pick up your Child/Ward from the program.
Name: / Relationship to Child:
Name: / Relationship to Child:
Name: / Relationship to Child:
Permission to leave Room 13 on his/her own (only for children over the age of 10): Yes___ No___
Parent/Guardian Initial______
Waiver:
I hereby release Harbourfront Community Centre (HCC) and all persons employed by or associated with HCC from all claims and causes of action resulting from the participation of my Child/Ward in the Weekend Room 13 Studio offered at HCC from Jan. 16th – Mar. 13th, 2016 (Saturdays or Sundays). Parent/Guardian Initial ______
Media Release:
I hereby agree and give my permission for my Child/Ward to be:
Audiotaped, filmed, interviewed, photographed, recorded and/or videotaped and to have this material/work - in
part or in whole - displayed, published and/or distributed through the media of film, multi-media presentations,
radio, social media sites, television, printed or display form.
I understand that the material/work may appear in electronic format on the internet or in other publications outside the control of the above-named agencies/partners/people. I agree that I will not hold the above-named responsible for any harm that may arise from such unauthorized reproduction.
I hereby waive any right to approve the use of this material/work now or in the future, whether that use is known to me or unknown, and I waive any rights to any royalties related to the use of the material/work.
I, the undersigned understand the release/permission information provided and give my permission as set above for my Child/Ward. Parent/Guardian Initial ______
Medical Release:
If I cannot be reached in the event of an accident or other medical emergency, I give permission for the personnel of Harbourfront Community Centre to obtain immediate qualified medical assistance for my Child/Ward. Treatment may include the administration of drugs, anesthetics, blood transfusions, injections or any treatment as noted to be needed by the physician caring for my Child/Ward. It is understood that every effort will be made to contact me immediately. Parent/Guardian Initial ______
Child Abuse Policy
All staff at Harbourfront Community Centre is required by law to report to Children’s Aid Society (CAS) if they are concerned for the well being of a child. If CAS is called, parents will be notified according to directions from the CAS worker. If abuse is suspected and medical attention required, the parent will be notified according to the direction from CAS. Parent Initial ______
Permission for Daily Excursions
Throughout the program, supervised groups of children frequently participate in daily outings. The staff at Harbourfront Community Centre would appreciate your permission for your Child/Ward’s participation in our outdoor excursions. These excursions are an important aspect of our program.I give my permission for my Child/Ward to participate in these outings. Parent/Guardian Initial ______
Parent/Guardian’s Signature: / Date:
The personal information on this form is collected under the authority of the City of Toronto Act, 2006, and Art. XI of Ch. 169 of the Toronto Municipal Code. The information is used to process your application for program participation; the registration of individuals in programs; payment of fees; collection of outstanding fee amounts; aggregate statistical reporting, contacting clients regarding upcoming programs, and, additional mailings. Questions about this collection can be directed to Leona Rodall, Executive Director, Harbourfront Community Centre, 627 Queens Quay West, Toronto, ON M5V 3G3.