Youth Job Skills Training Program Application

APPLICANT'S INFORMATION

Applicant's First & Last Name (required)

Applicant's Email Address (if applicable)

Applicant's Cell Number (if applicable)

Upload a photo of the applicant (5mb limit) (required)

Gender (required)
MaleFemale

Street address (required)

City (required)

Province (required)

Postal Code (required)

Date of Birth (YYYY-MM-DD) (required)

CONTACT INFORMATION

Parent/Guardian First & Last Name (required for applicants under the age of 18)

Parent/Guardian Phone Number (required for applicants under the age of 18)

Parent/Guardian Email Address (required for applicants under the age of 18)

Emergency Contact #1 Full Name (first and last) (required)

Phone Number (required)

Emergency Contact #2 Full Name (first and last) (required)

Phone Number (required)

HEALTH FORM

I give Extreme Outreach staff/volunteers permission to seek out all necessary medical advice and attention in the event of an emergency.

Allergies & Symptoms (list reaction(s) if any)

Other health notes for us to be aware of

Do you grant EOS Staff permission to give over-the-counter medications if necessary?
YesNo

PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR ACCEPTANCE

MEDICAL RELEASE:
I authorize the administration of any first aid treatment necessary at the Youth Job Skills Training Program for myself/my child. In the case of a medical emergency, I authorize myself/my child to be transported by designated leaders or arrange for transportation to the nearest medical or hospital facility. In such an emergency I hereby give permission to the physician involved to secure proper treatment for myself/my child. In the event extraordinary transportation or medical treatment is required, I agree that Extreme Outreach cannot accept the financial responsibility. I expect the parent/guardian/emergency contact to be contacted as soon as possible.

LIABILITY WAIVER:
Extreme Outreach reserves the right to dismiss a participant who in their opinion is a hazard to the safety and the rights of others, or who appears to have rejected the program rules as directed by the designated leaders. I am confident that Extreme Outreach staff will do their best to give myself/my child the necessary support and supervision needed and I understand that the safety and health rules will be observed. To the best of my knowledge, myself/my child is in good health and physically, emotionally, and socially able to participate in all activities. I give myself/my child permission to participate in all activities. I hereby release Extreme Outreach Society and its personnel from all claims and damages arising from any accidents or injury caused by my/my child’s participation in the program or by any transportation to and from all locations. Extreme Outreach is not responsible for lost, stolen, or damaged items during my/my child’s participation. I agree that photos or videos of myself/my child taken at the Extreme Coffee House may be used in future Extreme Outreach and/or SuperKids promotional material. If I am not in agreement with this, I will give written notice to Extreme Outreach that the photos and videos are not to be used for this purpose. The parent/guardian submitting this application for an applicant under the age of 18 are those having legal custody over the youth.

To indicate your understanding of the above, place a check mark in the box below and provide your full name and date:

I understand & agree

Full Name of Applicant

Full Name of Parent or Guardian

Date Signed