Greg Moore Youth Centre Youth Programs

PRC Youth Outreach Initiative Program

Participant Information:

Participant Name

Emergency Contact Name

Emergency Contact Phone

Address

Address 2

City/Town

Province/State

Postal Code/ZIP

Country

Participant Age

Participant Birthday

Participant Care Card Number

Other Information

Guardian Information

Parent/Guardian Name:

First

Last

Parent/Guardian Phone

Parent/Guardian Alternate Phone

A confirmation email with a copy of the submitted values will be sent to the address provided above.

Confirm Email

Signature

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Date of Signature

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Personal information entered on this form is collected under the authority of section 26(c) of the Freedom of Information and Protection of Privacy Act (FIPPA) for the purposes of processing your input. If you have any questions or concerns about how your information will be used, contact the FOI Office by calling 604-466-4300 ext. 5557 or by emailing FOI@MapleRidge.ca. For more information about FIPPA at the city, please visit our Freedom of Information page.

Greg Moore Youth Centre Youth Programs

Informed Consent Agreement

13–18 Years

Rules and Regulations

PRC Youth Outreach Initiative Program

Guardian Information