Youth in Action Registration / Inscription pour Jeunes en action

Name (First & Last)/Nom (Prénom & nom de famille) *

Date of Birth/ Date de naissance (DD/MM/YYYY) *

Participants' Gender Identity/Identité sexuelle *

Participants' Sexual Orientation/Orientation sexuelle *

Parent/Tutor/Gardian's Name - Nom du parent/tuteur *

Parent/Tutor/Gardians' Phone Number *

Address/Adresse *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email/Courriel *

Emergency contact / Contact d'urgence *

Emergency Contact Phone Number/Numéro du contact d'urgence *

Choice of Camp/Choix de camp *

Consent to Publicity/Consentement à la publicité *

Yes/Oui
No/Non

I give permission to the WNCHC to take photographs of my child during the Youth in Action camps. I understand that these photos may be used on advertisement to promote future camps. / Je permet au CSCNO de prendre des photos de mon enfant. Je comprends que ces photos peuvent être utilisées pour faire la promotion du camp de Jeunes en action.

Allergies

Medical conditions / Conditions médicales

Special needs / Besoins particuliers

Accessibility

West Nipissing Community Health Centre strives at all times to provide its services in a way that respects the dignity and independence of people with disabilities.

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Contact Us

68 Michaud St.
Sturgeon Falls, ON • P2B 1B8

Tel: : (705) 753-0151
Fax:: (705) 753-5387

info@cscno-wnchc.org Please be advised that this email should not be utilized for emergency purposes, to share medical information, or to book/cancel a medical appointment.

Hours of Operation

Mon, Tue, Thu: 8:00am – 4:00pm
Wed: 7:00am – 6:00pm
Fri: 8:00am – 1:00pm

The WNCHC has access to shared electronic medical records (EMR) through eHealth Ontario’s /ConnectingOntario/, but does not contribute any client information to this shared EMR.