Participant Information

First Name

Last Name

Address

City

Province ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNova ScotiaOntario

Postal Code

E-mail

Phone

Is the participant under 18? Is the participant under 18?YesNo

Relationship

Program/Event Program/EventCafecito con Gina BalsecaEmployment Preparation ProgramFuerza Latina Dance GroupChristmas PartyLatin Excellence Awards GalaMujeres Latinas NetworkVolunteers

How would you participate? How would you participate? Panelist Performer Audience

How many children are you register? How many children are you register? 1 2 3 4

Emergency Contact (Name and Phone Number)

Full name and age of the participants

First Name

Who is the main emergency contact? Who is the main emergency contact? Same emergency contact Other

Phone

Last Name

WAIVER

Relationship

I understand that in order to maintain an environment that is safe, inclusive and positive for all participants, Fuerza Latina Community Services reserves the right to dismiss a participant for any behaviour deemed as unacceptable. I understand that in order to maintain an environment that is safe, inclusive and positive for all participants, Fuerza Latina Community Services reserves the right to dismiss a participant for any behaviour deemed as unacceptable. Yes

I understand that I/my child/ward should not attempt to take part in any activity with which they are not familiar, without first receiving instructions. I also agree that I /my child/ward must abide by any policies of Fuerza Latina Community Services concerning the use and operation of its facilities. I understand that I/my child/ward should not attempt to take part in any activity with which they are not familiar, without first receiving instructions. I also agree that I /my child/ward must abide by any policies of Fuerza Latina Community Services concerning the use and operation of its facilities. Yes

I hereby release Fuerza Latina Community Services and its employees, servants and agents from any and all claims whatsoever, which may be caused by, or arise from my/ my child/ward’s participation in any and all activities and events online and in-person organized or sponsored by Fuerza Latina Community Services; except where the damage or injury is caused by the negligence of Fuerza Latina Community Services or its agents, officers and employees acting within the scope of their duties. I hereby release Fuerza Latina Community Services and its employees, servants and agents from any and all claims whatsoever, which may be caused by, or arise from my/ my child/ward’s participation in any and all activities and events online and in-person organized or sponsored by Fuerza Latina Community Services; except where the damage or injury is caused by the negligence of Fuerza Latina Community Services or its agents, officers and employees acting within the scope of their duties. Yes

I further agree that I, the undersigned, have no knowledge of any physical illness, disability or other reason that could cause my / my child’s/ward’s participation to prove hazardous to my/their health. I understand that by signing this consent waiver, I am allowing myself / my child/ward to actively participate in the activity as outlined above. I further agree that I, the undersigned, have no knowledge of any physical illness, disability or other reason that could cause my / my child’s/ward’s participation to prove hazardous to my/their health. I understand that by signing this consent waiver, I am allowing myself / my child/ward to actively participate in the activity as outlined above. Yes

PHOTO RELEASE CONSENT

I understand that by signing this form, I consent that the video, photographs and/or film in which I appear may be used by Fuerza Latina Community Services, its assigns or successors, to promote Fuerza Latina Community Services events and programs. Furthermore, I hereby consent that such photographs, films and recordings made shall be their property, and they shall have the right to sell, duplicate, reproduce, and make other uses as they may desire free and clear of any claim whatever on my part. This photo release will be used for Photographs/videos taken at any event offered by Fuerza Latina Community Services. I understand that by signing this form, I consent that the video, photographs and/or film in which I appear may be used by Fuerza Latina Community Services, its assigns or successors, to promote Fuerza Latina Community Services events and programs. Furthermore, I hereby consent that such photographs, films and recordings made shall be their property, and they shall have the right to sell, duplicate, reproduce, and make other uses as they may desire free and clear of any claim whatever on my part. This photo release will be used for Photographs/videos taken at any event offered by Fuerza Latina Community Services. Yes

REFUNDS and CANCELLATIONS

We reserve the right to cancel program(s) in the event of insufficient enrolment and/or attendance. A refund will be provided for any program that Fuerza Latina cancels before the programs’ start date. No refunds for annual registration fees after the programs’ start. We reserve the right to cancel program(s) in the event of insufficient enrolment and/or attendance. A refund will be provided for any program that Fuerza Latina cancels before the programs’ start date. No refunds for annual registration fees after the programs’ start. Yes

I understand all the terms and conditions above by signing this consent. I understand all the terms and conditions above by signing this consent.YesNo

- - Signature of Participant (over 18 years old) Parental/Legal Guardian Signature

Signature

Please type your name to be counted as an electronic signature Please type your name to be counted as an electronic signature Yes, I consent

Date (month/day/year)

I consent to receiving emails for Programs and Events from Fuerza Latina I consent to receiving emails for Programs and Events from Fuerza LatinaYesNo

Payment Payment I agree to proceed with a payment of $15 via e-transfer to [email protected]