IRCOM - ASP & HEY Registration Form Child First Name(Nécessaire)Child Last Name(Nécessaire)Genre(Nécessaire)MâleFemelleNon-BinaryInconnuAdresse(Nécessaire)Code Postal(Nécessaire)Phone (Cell)(Nécessaire)Phone (Home)Phone (Other)Statut d'immigration(Nécessaire)Canadian CitizenGovernment Assisted Refugees (GAR)Private Sponsored Refugees (PSR)Refugee Claimant (RC)Provincial NomineeUkraine CUAET PermitRésident permanentProtected PersonCountry of Origin(Nécessaire)Abu DhabiAfghanistanAlbanieAurignyAlgérieSamoa américainesAndorreAngolaAnguillaAntigua / BarbudaArgentineArménieArubaAustralieL'AutricheAzerbaïdjanBahamas Is.BahreïnBangladeshBarbadeBiélorussieBelgiqueBélizeBenin Peoples RepublicBermudesBhoutanBolivieBophuthatswanaBosnie HerzégovineBotswana Republic OfBrésilBrechouBrit. Virgin IslandsBrunéiBulgarieBurkina FasoBurundiCambodgeCamerounCanadales îles CanariesCape VerdeÎles CaïmansCent. African RepublicChad Republic OfChiliChine (RPC)ColombieComoresRépublique démocratique du CongoCongo Republic OfCook IslandsCosta RicaCroatieCubaChypreCzech RepublicDanemarkDjiboutiRépublique dominicaineÉquateurEgypteLe SalvadorAngleterreGuinée ÉquatorialeÉrythréeEstonieEthiopieFalkland Is.Federal Rep. Of GermanyFidjiFinlandeFormosaLe P. PolynésieFranceGuyane FrançaiseGabon RepublicGambieGéorgieGhanaGibraltarGrèceGroenlandGrenadeGuadeloupeGuamGuatemalaGuinea RepublicGuinée-bissauGuyaneHaïtiHondurasHong KongHongrieIslandeIndeIndonesia Republic OfL'IranIrakIreland, Republic ofIsraëlItalieIvory Coast RepublicJamaïqueJaponJordanKampuchéa démocratiqueKazakhstanKenyaÎles KerguelenKiribatiKorea NorthKorea SouthKosovoKoweitKirghizistanLaosLettonieLibanLesothoLibériaLibyeLiechtensteinLituanieLuxembourgMacaoMacedoniaMadagascarMalawiMalaisieMaldives, Republic OfMali, Republic OfMalteMarshall Is.MartiniqueMauritanieMauriceMayotteMexiqueMoldavieMonacoMongolia People's RepublicMontserratMarocMozambiqueMyanmarNamibieNauruNépalPays-BasNetherlands, Ant.NevisNouvelle CalédonieNouvelle-ZélandeNicaraguaNiger RepublicNigeriaIrlande du NordNorvègeOmanPakistanPalestinePanamaPanama Canal ZonePapouasie Nouvelle GuinéeParaguayPérouPhilippinesPitcairn Is.Polognele PortugalPorto RicoQatarRéunionRoumanieRussieRwandaSamoaSaint MarinSao Tome E PrincipeArabie SaouditeÉcosseSénégalSerbieles SeychellesSierra LeoneSingapourSlovaquie (République slovaque)SlovénieSolomons, TheSomalieSouth Africa, Republic OfSouth SudanEspagneSri LankaSt.HelenaSt.Kitts-nevisSt.LuciaSt.Pierre Et MiquelonSt.Vincent And The GrenadinesApatrideSudan Dem. Rep. OfSurinamSwazilandSuèdeSuisseSyrieTaïwan (ROC)TadjikistanTanzania, United Republic OfThaïlandeTibetTogo Republic OfTongaTrinidad & Tobago Dem. Rep. OfTunisieTurquieTurkménistanÎles Turques et CaïquesTuvaluU.S. Virgin Is.OugandaUkraineEmirats Arabes UnisRoyaume-UniUnited States Of AmericaUruguayOuzbékistanVanuatuVatican City St.VenezuelaViêt NamPays de GallesWallis And FutunaSahara occidentalYemen, Republic OfYougoslavieZaire, Republic OfZambieZimbabwePermanent Resident Card# (8 or 10 digits)Date of Birth (As per PR Card)(Nécessaire) JJ barre oblique MM barre oblique AAAA Current SchoolGradeGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Student NumberMHSC Health Insurance (P.H.I.N.)9 digitsRegistration number6 digits Parent/Guardian - Full Name(Nécessaire)Téléphone(Nécessaire)Emergency Contact - Full NameTéléphoneSelect the Program(s) you want to be involved whithChildren's Program (6-12 years)Homework Club (12-18 years)Youth Program (12-18 years)Health Information About the ChildPlease fill out any of the following that apply. The more information that we have allows us to better meet the needs of your child. Child has AllergiesCarries an EpipenChild Has AsthmaCarries an InhalerChild wears a medic-alert braceletMore detailsVeuillez fournir le nom, les détails, les symptômes et les déclencheurs de la maladie. Veuillez également inclure un plan de prise en charge et les exigences posologiques si des médicaments sont nécessaires.Emergency Care and Transportation PermissionI recognize that participation in IRCOM activities may expose my child to risk of injury. I agree not to hold IRCOM Inc. liable to any claims that may occur during any activity at IRCOM, or in its programs. I hereby grant IRCOM’s director and/or staff permission to secure proper medical treatment and transportation for my child to an appropriate facility for treatment, in case of emergency, and/or when I am unable to be contacted.(Nécessaire)OuiNonGeneral PermissionI hereby give permission for my child to participate in IRCOM’s After-School programs, including sports and recreation, homework, peer support and health workshops. I understand that my child may be suspended or expelled from this Program for fighting, or other disciplining reasons determined by program staff and/or director. I understand that IRCOM Inc. does not provide daycare services, and children are free to come and go as they please. I understand that should my child leave while attending the program, she/he is no longer in care of the program staff.(Nécessaire)OuiNonPhotograph ApprovalI hereby authorize the IRCOM staff to take photographs of my child named in this application during program activities, and to display and otherwise use these photographs without charge, and solely for the purpose of promoting and reporting on programs at IRCOM. (Nécessaire)OuiNonParent/Guardian's SignatureSign Date JJ barre oblique MM barre oblique AAAA Off-Site Programs and activities Permission This is to certify that I allow my child to attend off-site activities through the Immigrant and Refugee Community Organization of Manitoba (IRCOM) Inc. These activities may include, but are not limited to homework, sports games and practices, gym, community events, swimming, bowling, movies etc. I am aware that all youth participating in these programs will be supervised at all times by staff members and volunteers of IRCOM Inc. I agree that IRCOM Inc.is not responsible for any loss or damage to personal property or bodily injury suffered by the youth before during or after the activity.Parent/Guardian's SignatureSign Date JJ barre oblique MM barre oblique AAAA Homework, Education and Youth Consent to Share Information The Homework, Education and Youth (HEY) Program is part of the after school programs of the Immigrant and Refugee Community Organization of Manitoba (IRCOM) Inc. and works in partnership with Winnipeg schools. HEY program staff may speak with staff of the participant’s school (e.g. teachers, guidance, administrators) when appropriate to support the youth and his/her family to achieve academic and social goals. I give permission to the Homework, Education and Youth Program to share information with staff of my child’s school or other programs of IRCOM as necessary to ensure that my child receives appropriate education and social support, programming and is able to successfully participate in and benefit from the HEY Program. I understand that information regarding my child’s school attendance and academic progress including course grades, as well as participation in HEY tutoring, literacy, leadership mentoring and enrichment may be shared with IRCOM staff and mentors when necessary, to support participation and success in the HEY Program. I understand that the HEY Program will not release information to any other person or agency without my consent, except when required by law. I have read and agreed to the above terms:Signature of GuardianSign Date JJ barre oblique MM barre oblique AAAA Witness (IRCOM staff)Sign Date JJ barre oblique MM barre oblique AAAA This field is hidden when viewing the formFor IRCOM Administrative Use OnlyThis field is hidden when viewing the formToday's Date MM barre oblique JJ barre oblique AAAA This field is hidden when viewing the formProgrammeThis field is hidden when viewing the formConsent1This field is hidden when viewing the formConsent2This field is hidden when viewing the formConsent3This field is hidden when viewing the formConsentscommentairesCe champ n'est utilisé qu'à des fins de validation et devrait rester inchangé.