Participant's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Phone

(###)

###

####

Does the participant have any special needs (dietary, allergies, mobility, behavioural, etc.) that we should be aware of? *

Yes

No

Do you permit photographs, audio, and/or video to be taken of your child while engaged in PAF Safety Day activities (images will be used to promote safety in the media, social media, websites, and in promotional materials)? *

Yes

No

Will you allow your child to participate in a knowledge-based survey before, during, and/or after the PAF Safety Day to help evaluate the effectiveness of the program? *

Yes

No

If your child becomes ill or injured during their participation in the PAF Safety Day, do you allow first aid to be administered (please note, in the event of a serious injury or illness, the emergency contact will be notified)? *

Yes

No

Person Responsible for Participant *

** NOTE: All parents/guardians are required to SIGN OUT their children with their group leader prior to leaving the Safety Day. **If the participant’s parent/guardian will not be picking them up at the end of the day, please indicate who will sign out and be responsible for the participant.

First Name

Last Name

Volunteer Willingness *

Please check if you are willing to assist as a group leader for the morning.

Yes

No

Your Name/Name of Parent/Guardian *

Completing this field confirms that the information provided is complete and accurate, and that you understand the information in this consent form.

First Name

Last Name