Junior Youth Empowerment Program Registration Parents of new junior youth are required to attend an information session. We will be in touch to invite you to an upcoming session. Name of Participant * First Name Last Name Date of Birth * MM DD YYYY Home Address * Applicants are required to reside and/or attend school in the Edmonds neighbourhood of Burnaby School * Grade * Medical conditions, allergies * Availability * Please select all days that apply: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Name of Parent/Guardian * First Name Last Name Phone * (###) ### #### Email * How did you hear about the program? * Image Release * Do you permit the use of photos and videos taken of the group’s activities that include your son/daughter to be used in the program’s promotional materials (eg. brochures, Instagram)? Yes No I hereby give permission for my son/daughter to attend this summer program. I understand that the Junior Youth Empowerment Program will endeavor to provide my son/daughter with a safe environment. In the case of personal injury, loss or damage I, or a third party, will not hold Junior Youth Empowerment Program, its agents or volunteers responsible. Yes Thank you for completing our registration. We will be in contact within a few days.