Registration #
Registration Form 2016
PEEP for Tots!
Winter Session 1: Jan. 11 – Feb. 9, 2016
Program Hours and Fees
Age: 2 Yrs.
Subsidy Information:
Program Days: Mondays, Tuesdays
Subsidy requested: Yes [ ]
No [ ]
Please complete the fee assistance Application form.
Program Hours: 9:30 a.m. to 11:30 a.m.
Session One Program Fee:: $220/child
A minimum of 5 participants is required in
order to operate the Program.
PLEASE NOTE:
 The Fee Assistance Program is offered on a
first- come, first- serve basis and is limited upon
availability of funds.
 Processing applications may take up to 14
days after being received by HCC.
Personal Information
Child/Ward Name:
Date of Birth(dd/mm/yyyy):
Mailing Address:
Postal Code:
Parent/Guardian #1 Name:
Parent/Guardian #2 Name:
Home Phone:
Home Phone:
Work Phone:
Work Phone:
Cell Phone:
Cell Phone:
Email Address:
Email Address:
Emergency Care
Emergency Contact:
Emergency Phone:
Relationship to Child:
Medication currently take by child:
Name of Child’s Physician:
Physician’s Phone:
Health Card Number:
Allergies/dietary restrictions:
Child Release Authorization: person(s) on this list will be permitted to pick up your child from Program.
Name:
Relationship to Child:
Name:
Relationship to Child:
Name:
Relationship to Child:
HCC Policies-PLEASE READ ALL POLICIES CAREFULLY. You agree to the following HCC Policies by
signing this Permission Form:
I hereby release the Harbourfront Community Centre (HCC) and all persons employed by or associated
with the HCC from all claims and causes of action resulting from the participation of my child/ward in
the HCC Peep for Tots!
Permission for Daily Excursions:
Throughout the program, supervised groups of children frequently participate in daily outings. The staff
at Harbourfront Community Centre would appreciate your permission for your child’s/ward’s
participation in our outdoor excursions. These excursions are an important aspect of our program. I
give y permission for my child/ward to participate in these outings. I understand that outing
permission forms for larger trips will be provided to parents/guardians.
By signing this Permission Form I agree to all of the HCC Policies
and Permissions noted on this document.
Parent/Guardian Signature:
Date:
Parent/Guardian Name (Please Print):
Media Release Policy:
I hereby agree and give my permission for my child(ren)/ward(s) to be:
Audiotaped, filmed, interviewed, photographed, recorded and/or videotaped and to have this
material/work - in
part or in whole - displayed, published and/or distributed through the media of film, multi-media
presentations,
radio, social media sites, television, printed or display form.
I understand that the material/work may appear in electronic format on the internet or in other
publications outside the control of the above-named agencies/partners/people. I agree that I will not
hold the above-named responsible for any harm that may arise from such unauthorized reproduction.
I hereby waive any right to approve the use of this material/work now or in the future, whether that
use is known to me or unknown, and I waive any rights to any royalties related to the use of the
material/work.
I, the undersigned understand the release/permission information provided and give my permission as
set above for child(ren)/ward(s). Parent Initial ____________
Medical Release Policy:
If I, ___________________, cannot be reached in the event of an accident or other medical emergency, I
give permission for the personnel of Harbourfront Community Centre to obtain immediate qualified
medical assistance for my child ___________________. Treatment may include the administration of
drugs, anesthetics, blood transfusions, injections or any treatment as noted to be needed by the
physician caring for my child. It is understood that every effort will be made to contact me immediately.
Parent Initial ____________.
Child Abuse Policy
All staff at Harbourfront Community Centre are required by law to report to Children’s Aid Society
(CAS) if they are concerned for the well being of a child. If CAS is called, parents will be notified
according to directions from the CAS worker. If abuse is suspected and medical attention required, the
parent will be notified according to the direction from CAS. Parent Initial ____________
Parent’s Signature:
Date:
The personal information on this form is collected under the authority of the City of Toronto Act, 2006, and Art. XI of Ch. 169 of
the Toronto Municipal Code. The information is used for the registration of individuals in programs; aggregate statistical
reporting, contacting clients regarding upcoming programs, and, additional mailings. Questions about this collection can be
directed to Leona Rodall, Executive Director, Harbourfront Community Centre, 627 Queens Quay West, Toronto, M5V 3G3.
Payment and Subsidy Request (for Office Use Only)
Subsidized fee per week _______________
Payment amount ___________________
Date ___________________
Staff Witness _________________
Receipt #________________
HCC Membership #:______________