Please Read Through and Fill out This Form Carefully

Bathurst Sustainable Development’s YOUTH ENVIRONMENTAL LEADERSHIP PROGRAM (YELP) Registration Form and Parent/Guardian Permission Form

Please read through and fill out this form carefully. If you have any questions or concerns, please contactBathurst Sustainable Development: 506.548.8470 or 506.548.2106 or [email protected].

Child’s full name: ______Date of birth (dd/mm/yy):______

YOUR INFORMATION (for emergency contact purposes): Name(s) of Parent/Guardian:______Email: ______Address: ______

Home Phone Number:______Work #:______Cell: ______

ALTERNATE EMERGENCY CONTACT INFORMATION Full name:______Relationship:______Phone #1:______Phone #2:______

MEDICAL INFORMATION: Health card #:______Allergies: ______Medical conditions: ______*Medications: ______

I hereby grant my permission for my child ______to participate in the Environmental Leadership Program (hosted by Bathurst Sustainable Development) on Tuesday mornings (8-10am) and Wednesday mornings (9-11am), from July 5th to August 17th, and at the Eco Fair (Saturday, August 13th).

Hold Harmless Clause

I hereby agree to hold harmless the City of Bathurst, Bathurst Sustainable Development and the Victoria Park Enhancement Committee for any liability, damage, loss, or claim that occurs on behalf of my child in connection with the activities of the Leadership program taking place in the community garden or park area, or while at the Climate Change Action Center .

Signed (Parent/Guardian): ______

Today’s date (dd/mm/yy): ______

OTHER INFORMATION: Cost = Free Transportation: Parents/Guardians are responsible for transporting their child to the locations listed above. Equipment/Gear to bring when at the garden:  Sunscreen  Hat  Appropriate clothing and footwear to wear while working in a garden (no open toed shoes, please)  Folding lawn chair or blanket to sit on grass  Snack & LOTS of water  Notebook & pen/pencil

*Please note that if your child requires special medication (ex. epi-pen), that you must ensure that the child brings that medication to each event, and please provide us with instructions on how to administer it if required.