பதிவுப் படிவம் Step 1 of 3 33% Basic Information Add a Child/ Other Adult Waiver and Policies Name* FIRST NAME LAST NAME Password* PASSWORD CONFIRM PASSWORD Minimum 10 characters with the combination of following items (use upper and lower case letters, numbers and symbols like ! " ? $ % ^ & )Address* address Apt# City Postal Code PHONE (PRIMARY)*PHONE SECONDARY (optional)Email* GENDER*MALEFEMALEOTHERAGE GROUP*14+21+24+35+42+49+56+63+70+77+84+91+ALLERGY*SPECIAL NEEDS*NoneOtherPrefer not to discloseOTHER SPECIAL NEEDS (optional)Emergency Contact Person Name*EMERGENCY contact person PHONE #*How did you hear about our program ?*AgencySchoolNewspaperWord of mouthFriendFlayerTVOther Basic Information Add a Child/ Other Adult Waiver and Policies You can add upto 5 individualsAdd Child (Under 14) / Other Adults*YesNoFirst Child / Adult* FIRST NAME LAST NAME BIRTHDAY* Date Format: DD dash MM dash YYYY RELATION*ALLERGY*SPECIAL NEEDS*NoneOtherPrefer not to discloseOTHER SPECIAL NEEDS (optional)GENDER*MALEFEMALEOTHERAdd Another Child (Under 14) / Other Adults*YesNo2nd Child / Adult* FIRST NAME LAST NAME BIRTHDAY* Date Format: DD dash MM dash YYYY RELATION*ALLERGY*SPECIAL NEEDSNoneOtherPrefer not to discloseOTHER SPECIAL NEEDS (optional)GENDER*MALEFEMALEOTHERAdd Another Child (Under 14) / Other Adults*YesNo2nd Child / Adult* FIRST NAME LAST NAME BIRTHDAY* Date Format: DD dash MM dash YYYY RELATION*ALLERGY*SPECIAL NEEDS*NoneOtherPrefer not to discloseOTHER SPECIAL NEEDS (optional)GENDER*MALEFEMALEOTHERAdd Another Child (Under 14) / Other Adults*YesNo2nd Child / Adult* FIRST NAME LAST NAME BIRTHDAY* Date Format: DD dash MM dash YYYY RELATION*ALLERGY*SPECIAL NEEDS*NoneOtherPrefer not to discloseOTHER SPECIAL NEEDS (optional)GENDER*MALEFEMALEOTHERAdd Another Child (Under 14) / Other Adults*YesNo5th Child / Adult* FIRST NAME LAST NAME BIRTHDAY* Date Format: DD dash MM dash YYYY RELATION*ALLERGY*SPECIAL NEEDS*NoneOtherPrefer not to discloseOTHER SPECIAL NEEDS (optional)GENDER*MALEFEMALEOTHER Basic Information Add a Child/ Other Adult Waiver and Policies Waiver In consideration of the acceptance of the accompanying application to participate in the programs/services offered by Malvern Family Resource Centre, I hereby release and forever discharge Malvern Family Resource Centre together with its directors, officers, employees, agents and representatives (collectively "the Organization") from any and all actions, causes of actions, claims and demands for and howsoever arising which I may hereafter have against the Organization in respect of personal injury or property damage sustained during my participation in the specified activities or which may otherwise occur in the course of participating in any other activities, including, without limitation, as a result of the granting of any consent by the Organization on my behalf to emergency medical treatment. I further agree to indemnify and hold harmless the Organization from any claims that may be asserted against the Organization by third parties in respect of the aforesaid personal injury or property damage or in respect of the Organization's consent to any necessary medical treatment on my behalf. In case of emergency, accident, or illness, I authorize the Organization to consent to any necessary medical treatment and hereby ratify and confirm, and agree to ratify and confirm, whatever actions the Organization may lawfully take in that regard. Consequently, I take full responsibility for all costs incurred. I acknowledge having read, understood, and agreed to this Waiver Form and agree to accept all risk for any harm associated with my participation in the program. I acknowledge that the Organization has relied upon the information set forth in this application form in agreeing to accept me into the program and hereby warrant that the information is complete and correct in all respects. Photograph Release I give Malvern Family Resource Centre permission to use my, and/or my child’s photograph, video, and any photographs or videos in which I/my child appear, for our archives, and in any reports or material used to promote the Malvern Family Resource Centre and its programs. I understand I will not be reimbursed in any way for use of such photographs, and permission.Consent* I agree to the Waiver and Photograph Release statements above.*