GHC Registration

Student information

First name *

Last name *

Preferred name (optional)

Address *

City *

Postal code *

Date of birth *

School *

Grade *

Care Card # (optional)

Student contact number (optional)

Length in Canada (optional)

Place of birth (optional)

Child welfare legal status (if any)

Not applicable Temporary care Permanent care Alumni (formerly in permanent care)

Do you identify with a population over-represented in child welfare? (optional)

Aboriginal / First Nation / Metis / Inuit Black / Biracial Other

Please describe

Parent / guardian information

Parent / guardian 1

First name *

Last name *

Relationship to student *

Home phone (optional)

Cell phone *

Email *

Parent / guardian 2 (optional)

First name

Last name

Relationship to student

Home phone

Cell phone

Email

Emergency contact

Emergency contact 1

First name *

Last name *

Relationship to student *

Emergency contact number *

Preferred language (optional)

Emergency contact 2 (optional)

First name

Last name

Relationship to student

Emergency contact number

Preferred language

Important health and support information

The information you provide is confidential. It is to assist staff to best support your child and to ensure their success in this program. Generations Homework Club is designed to support students who may be hesitant to engage with traditional tutoring or mentoring programs due to extenuating circumstances. As such, staff and volunteers receive specialized training to effectively address a wide range of challenges these students may encounter.

Does the student have any allergies? *

Yes No

Details

Does the student have any health concerns? *

Yes No

Details

Does the student take any medication? *

Yes No

Details

Is the student diagnosed with a Special Learning need? *

Yes No

Details

Is the student suspected to have a Special Learning need? *

Yes No

Details

Does the student have an Educational Assistant at school? *

Yes No

Details

About your child

Please tell us about your child’s educational strengths in school. (maximum 100 words)

0 / 100 words

Please tell us about your child’s educational challenges in school. (maximum 100 words)

0 / 100 words

What are your expectations for GHC? Please choose one option in each category.

Academic improvement * (e.g. complete course, improve grade, apply to post-secondary)

Behavioural gains * (e.g. improve school attitude, improve attendance, improve writing)

Social improvement * (e.g. improve peer relations, improve instructor relations)

Emotional gains * (e.g. improve confidence in school, improve confidence in subject)

Academic profile

In which academic areas does your child need support? * (check all that apply)

At what academic level does your child work? *

Works below grade level Works at grade level Works above grade level

How does your child interact with their peers? *

Positively Little to no interaction Negatively / aggressively

How does your child interact with authority figures? *

Respectful Challenging Defiant

How would you describe your child’s self-esteem? *

Healthy Over-compensates Struggling Negative

Does your child receive additional support at school? *

Yes No

What type(s) of support?

Other comments, notes or helpful resources when working with your child (optional)

Workbook

Which workbook format would you like? *

Softcopy (free) Hardcopy (printing cost)

Program activities participation consent

Name of parent / guardian *

Name of the applicant

Filled in from the student’s name.

I, __________, hereby authorize the applicant, __________'s participation in the Generations Homework Club supported by Connections Community Services Society (CCSS). I understand and acknowledge that each participant must assume the risk and any related financial responsibility that could result from participation in the activities provided by the Connections Community Services Society and its partners. I agree to assume such risks and responsibilities.

I understand that CCSS or their partner agencies are not responsible for the providing or administering of medication to any youth. I agree to make arrangements for my child to have all the necessary medications that they need and the means to take them when required. In case of sickness or accident, CCSS has my approval to secure such medical attention as deemed necessary if I am unable to be contacted. I further understand that neither CCSS, nor any of its paid or volunteer workers can be held responsible in the event of an accident.

I also authorize CCSS staff and volunteers (tutors) to collect information that will help evaluate the effectiveness of the program. Any information collected will be confidential and any reports or summaries made will not identify participants.

I have provided accurate information and disclosed all relevant medical details and any other information that may impact on the participation and supervision of the applicant.

By signing this form I declare that I have fully read the forms and HEREBY RELEASE AND FOREVER DISCHARGE Connections Community Services Society, its employees, volunteers, directors/agents, partners, and funders of and from all manner of actions, causes, claims, and demands of whatsoever nature which my child may have in respect of any injury, loss or expense he/she sustain arising out of or in any way connected with his/her participation in CCSS Generations Homework Club.

I have read and agree to the participation consent above. *

Consent for photography

Furthermore, I Do / Do Not give permission to the employees and volunteers or CCSS to take pictures of the applicant and use the resulting photographs in promotional materials developed by the organization. This consent is valid for one year from the date of this form and may be cancelled at any time by writing CCSS.

I do give permission I do not give permission

Signature of parent / guardian *

Sign here with your mouse or finger

All information collected will be used for the sole purpose of Connections Community Services Society programming. All information is confidential and will not be shared with any third-party groups except staff & tutors.

Generations Homework Club

When and where

Student information

Parent / guardian information

Parent / guardian 1

Parent / guardian 2 (optional)

Emergency contact

Emergency contact 1

Emergency contact 2 (optional)

Important health and support information

About your child

What are your expectations for GHC? Please choose one option in each category.

Academic profile

Workbook

Program activities participation consent

Consent for photography

Registration received

Executive Director / CEO