Information Form Children'S Programs
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1Information Form
Children’s Programs
Active Living & Culture
1800 Parkinson Way
1620-01
Kelowna, BC V1Y 4P9
250 469-8800
kelowna.ca/recreation
CONTACT INFORMATION
PARENTS: This form is to help us provide a safe and enriching environment for children.
Please complete all sections and return to the instructor on or before the first day of class.
Name of Program: ________________________
Location: _____________________________
Child’s Name:
Name of person(s) authorized to pick up your
child (including parents):
Phone:
Date of Birth:
Mother’s Name:
Father’s Name:
Contact in case of emergency:
Child will not be allowed to leave with anyone
Phone:
Cell:
who is not on this list
Would you like to assist with any of the activities? □ YES
□ NO
Authorization for your child’s picture to be taken/used for Active Living & Culture publicity.
Parent/Guardian Signature _________________________
Date ____________________
Would you like to receive Active Living & Culture notifications by email?
Email:________________________________________________________________________________________
MEDICAL INFORMATION
Doctor’s Name:
Phone:
Allergies:
Disabilities:
Medications:
Authorization in case of emergency:
In case of an accident (or serious illness), I authorize Active Living & Culture staff to contact a
physician or ambulance if I, or any other specified guardian, cannot be contacted immediately.
Parent/Guardian Signature
Date
NOTICE OF COLLECTION OF PERSONAL INFORMATION
Personal information on this form is collected under the authority of the Municipal Act, R.S.B.C. 1996, c323 and the Freedom of Information and
Protection of Privacy Act, R.S.B.C. 1996, c165 and is necessary for the operation of the City of Kelowna recreation programs and related activities.
Questions about the collection of this information are to be directed to the Active Living & Culture Manager, Parkinson Recreation Centre, 1800
Parkinson Way, Kelowna, BC, V1Y 4P9, 250 469-8800
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