Front Line Staff Use - Support InformationThis participant has: Disability: □ Yes □ No (√ )

Life Threatening Allergy: □ Yes □ No (√ )Other: (specify) _______________________________

Front Line Staff Use - Form DistributionForms sent to participant:

Date: Staff Initial:Forms receivedSite: _______Date: Staff Initial:Forms forwardedSite: _______Date: Staff Initial:

Programs are listed alphabetically by location.Please place a √ (check) in the box or circle each camp your child is registered in.* Bill Copeland Sports Centre Oct Nov Febemail: Arlene.Mann@burnaby.ca Pro D Days (5-12 yrs) 25 22 28* Bonsor Recreation Complex Oct Nov Febemail: Kelli.Tibbles@burnaby.ca Pro D Days (6-12 yrs) 25 22 28

Dec Dec Dec/JanWinter Break Celebrations (6-12 yrs) 23 27 30-3

Mar MarSpring Break Spectacular (6-12 yrs) 16-20 23-27

email: Laurie.Jones-Tome@burnaby.ca Exclusively …ARTS! (6-12 yrs) 16-20Byte Camp: Intro to Coding (9-12 yrs) 23-27

* Burnaby Village Museum Sept Oct Nov Feb Mar MarForging Fridays (13-16 yrs) 6 4 1 7 6Heritage Adventure Pro D Day Camp (6-9 yrs) 27 22 28

email: Lorenda.Calvert@burnaby.ca

email: Kate.Procopio@burnaby.ca Spring Break Heritage Adventure Camp (6-9 yrs) 16-20 23-27After Camp Club (6-9 yrs) 16-20 23-27

* Cameron Recreation Complex Oct Nov Dec/Jan Feb Mar Maremail: Tim.Macvinnie@burnaby.ca Cameron Winter Camp (6-9 yrs) 30-3

Cameron Spring Break Camp (6-9 yrs) 16-20 23-27Pro D Days (6-9 yrs) 25 22 28

* Warner Loat Park Maremail: Laurie.Bedford@burnaby.ca Camp Madawaska - Spring (6-12 yrs) Oct Nov Feb 16-20

Pro D Days (9-13 yrs) 25 22 28 Mar* Creekside Youth Centreemail: Mark.Frouws@burnaby.ca Camp Madawaska Leadership Spring (11-15 yrs) 16-20* Edmonds Community Centre Oct Nov Febemail: Daniela.Tench@burnaby.ca Pro D Day Camps (6-12 yrs) 25 22 28

After - Camp Stay & Play (6-12 yrs) 25 22 28Dec Dec Dec Dec Dec Dec Jan Jan

Winter Break Celebrations (6-12 yrs) 23 24 26 27 30 31 2 3After-Camp Stay & Play (6-12 yrs) 23 26 27 30 31 2 3

Mar Mar Mar Mar Mar Mar Mar Mar Mar MarSpring Break Spectacular (6-12 yrs) 16 17 18 19 20 23 24 25 26 27After-Camp Stay & Play (6-12 yrs) 16 17 18 19 20 23 24 25 26 27

Jan Maremail: Andrea.Anthony@burnaby.ca Exclusively...Arts! (6-12 yrs) 2-3 23-27

After-Camp Stay & Play (6-12 yrs) 2-3 23 24 25 26 27Pro D Day Outtrips Oct Feb

email: Dean.Valdecantos@burnaby.ca Laser Tag & Swim (10-15 yrs) 25 28Mar* Ron McLean Park

email: Mikaela.Graham-Radford@burnaby.ca Byrne Creek Outdoor Camp (6-12 yrs) 23-27Oct Nov Feb Mar Mar* Shadbolt Centre for the Arts

email: Lia.Miller@burnaby.ca Shadbolt Adventures in Art: Pro D Days 25 22 28Spring Break Arts Jam (6-10 yrs) 16-20Spring Break Circus Camp (7-12 yrs) 23-27After-Camp Fun (6-10 yrs) 25 22 28 16-20

email: Marianne.Otterstrom@burnaby.ca Camp - Arts Break (6-12 yrs) 23-27* Wesburn Community Centre Mar Mar Mar Mar Mar Mar Maremail: Louise.Rusch@burnaby.ca Spring Break Spectacular (5-8 yrs) 16 17 18 19 20 16-20

Spring Break Youth Zone (9-11 yrs) 16 17 18 19 20 16-20Spring Break Spectacular (5-8 yrs) 23 24 25 26 27 23-27Spring Break Youth Zone (9-11 yrs) 23 24 25 26 27 23-27After Camp Club (5-11 yrs) 16-20 23-27

Oct Nov Feb Mar MarBabysitters Basics Spring Break Camp (11-15 yrs) 16-20Spring Ventures (6-10 yrs) 16-20 23-27Pro-D Day Camp (6-10 yrs) 25 22 28

Sept MarPro-D Day Game Design (7-11 yrs) 30Game Design Camp (8-12 yrs) 23-27

Participant Package - Updated July 2019 Final

Fall/Winter/Spring Break 2019/2020Participants Name:

Personal information is collected and used under the authority of the Freedom of Information and Protection of Privacy Act s.26 © for the purpose of administering parks, recreation and cultural programs. For more information contact the Admin Office @ 604-294-7450

* Willingdon Community Centreemail: Carmela.Cavaleri@burnaby.ca email: Jamie.Barber@burnaby.ca

email: Lucas.Bjerke@burnaby.ca

Participant Package

Please register your child in the program. Register online at www.burnaby.ca/webreg or in person at a Community Centre. All children must be currently attending or have completed Kindergarten to participate in these programs. Once registered, ALL participants must complete a Participant Package. These forms are required two to three weeks before program start. Save time and help ensure a quality experience for your child by taking a moment to complete all forms when registering. Once complete mail or drop-off the forms to the appropriate community centre or email to the programmer.

Participant Name:

Participant Profile Form

Program: Date/Time:

Season/Year: Location:

This information is for staff use. The standard response in the event of a medical emergency is to call 9-1-1, then call the parent or guardian. Information on thisform may also be provided to 9-1-1 personnel in the event of an emergency.

First Last

EMERGENCY CONTACT:

I understand that I am responsible for immediately notifying the staff/supervisor of changes to this information.

__________________________________________ ________________________________ Signature of participant (19 years & older) or parent/guardian/caregiver Date

Home Phone: Cell Phone:

Work Phone: Other Phone:

Address:

Email: Language(s):

Parent/Guardian:

First Last

Birth Date: / / Gender:

Year Month Day

No Yes

No Yes

No Yes

No Yes

No Yes

Does participant have a life-threatening allergy/condition?

Does participant have an epi-pen?

Does participant require assistance in order to participate in this program? (Note: Please bring an attendant, caregiver or family member if you require personal care support such as changing,

transferring, washroom assistance, or administration of medication.)

Does participant have behaviours that staff should be aware of? ____________________________

Does participant have a disability?

Is there anything else we need to know about the participant? _____________________________(for example: medical conditions, dietary restrictions, general allergies, fears, etc.)

No Yes

Please Note: This information helps staff determine if we can safely accommodate the participant in our program. If you have indicated “Yes” to any of the above questions, you must speak with staff before your child can participate in the program. Next step: Complete the Program Support Package.

PICK-UP AUTHORIZATION: The following people are authorized to pick up the participant in the event of an emergency or in my absence.

Authorized Persons First & Last Name Relationship to Participant Contact Phone #

SIGN IN AND OUT AT SELECT LOCATIONS (*) My child is permitted to:

Sign themselves "IN" to the program No Yes Sign "OUT" and leave unaccompanied at the end of program No Yes

Name of Emergency Contact(s):

First Last

Relationship to participant: Phone:

Parks Admin: DC Jun 2019Personal Information is collected and used under the authority of the Freedom of Information and Protection of Privacy Act s. 26 (c) for the purpose of administering parks, recreation and cultural programs. For more information, contact the Admin Office 604-294-7450.

(for school aged children; not applicable for those in preschool/kindergarten)

Parks, Recreation & Cultural Services Department Program Waiver: Minor Participants under the age of 19

Parks Admin: DW Feb 2019

INFORMED CONSENT WAIVER, RELEASE, AND INDEMNITY

FOR PARTICIPANTS UNDER THE AGE OF NINETEEN (19) (Read Carefully Before Signing)

BETWEEN: The City of Burnaby (the City)

AND: _____________________________________________________________________________ (Parent and/or Legal Guardian)

This form must be properly completed and executed by the parent or legal guardian of all participants that are under the age of nineteen (19) years at the date of signing.

NOTICE TO PARENT AND/OR LEGAL GUARDIAN The City of Burnaby requires execution of this document by a parent or legal guardian as a reminder and confirmation of their duty to inform themselves of the risks normal to the activity they have chosen for the child participant and of their responsibility to carefully consider those risks against their personal knowledge of the ability and experience of the child. This is for the protection of the child enrolled, other participants and the City. It does not apply to incidents that arise out of the sole negligence of the City.

PARTICIPANT NAME: (the Participant)

I, THE UNDERSIGNED parent and/or legal guardian of the Participant hereby acknowledge that I have informed myself to my own satisfaction of the risks associated with or inherent in any program or activity offered by the City and in which I have registered the Participant. I consent to participation by the Participant in all aspects of the program offered and further agree as follows:

PARENT AND/OR LEGAL GUARDIAN TO INDEMNIFY AND SAVE HARMLESS: That in consideration of the fee to be paid and instruction or other services to be provided, and excepting only the sole negligence of the City, I hereby agree to Indemnify and Save Harmless the City and its officers, servants, agents, and co-sponsoring organizations from any claims, demands, and causes of action that may arise out of participation by the Participant in the program named below.

PARENT AND/OR LEGAL GUARDIAN TO RELEASE AND WAIVE CLAIMS: That on behalf of myself, my heirs and assigns, and excepting only the sole negligence of the City, I hereby Release, Waive, and forever discharge the City and its officers, servants, agents, and co-sponsoring organizations, from all claims, costs, causes of action, or demands that may arise out of any incident, accident, or other occurrence that may result in personal or bodily injury, loss of life, property loss, or any other damages to any person by or through participation by the Participant in the program identified below.

DATED THIS _____ day of __________________, 20____.

This is the City’s standard form of Waiver for participants and cannot be altered. 

(Signature of Parent or Legal Guardian)

(Reviewed for Completeness by Staff)

Program Name: (or see attached)

___________________________________ Program Type:

___________________________________ Co-Sponsors:

___________________________________ Program Dates:

___________________________________ Location:

___________________________________

Personal Information is collected and used under the authority of the Freedom of Information and Protection of Privacy Act s. 26 (c) for the purpose of administering parks, recreation and cultural programs. For more information, contact the Admin Office 604-294-7450.

The personal information collected on this form is authorized under section 26 of the Freedom of Information and Protection of Privacy Act

for the purpose(s) set out on this form. Should you have any questions about the collection of this personal information please contact

us by mail at: Corporate Communications & Marketing, #215-4946 Canada Way, Burnaby, British Columbia V5G 4H7, by telephone at

604-570-3636 or by email at communications@burnaby.ca

Updated December 2018

Photo/Audio/Video Release

Event or Program: ____________________________ Date:_____________________________

Photographer/Videographer: ___________________________________

I, __________________________ hereby: (a) grant the City of Burnaby (the “City”) and its elected officials,

officers, employees, agents, contractors, nominees and delegates, including the above-named

Photographer/Videographer (collectively, the “City Personnel”), the right to take photographs, video and audio

recordings of me (collectively, the “Recordings”); and authorize the City to use, and publish the Recordings in

whole or in part for any lawful purpose, including for such purposes as publicity, advertising, promotion,

editorial, web content, social media, public displays and exhibitions. The foregoing consent is effective on the

date shown above and shall remain in effect indefinitely, unless I revoke it earlier, in writing.

I acknowledge and agree that the City owns and retains all right, title and interest in and to the Recordings. I

hereby waive any rights to approve the use of the Recordings now or in the future, and waive any right to any

royalties or any other form of compensation related to the use of the Recordings.

I hereby release and discharge the City and City Personnel from any and all claims and demands arising out of

or in connection with the use of the Recordings, including, without limitation, any and all claims for libel or

violation of any right of publicity or privacy.

By signing below, I confirm that I have read, understand, and agree to be bound by, the terms of the

consent and release set out above:

Print Name:

Signature:

Date:

Address:

If individual named above is 18 years or under:

I am the parent or legal guardian of the individual named above. By signing below, I confirm that I have read,

understand, and agree to be bound by, the terms of the consent and release set out above.

Print Name:

Signature:

Date:

Address: