Participant Name

First Name

Last Name

Name of Parent/Guardian *

If participant is 18 or older, please enter "N/A"

First Name

Last Name

Phone Number *

(###)

###

####

Age of participant *

14 - 17

18 - 20

21 - 24

Will a parent/guardian be joining the session with the youth participant? *

Note: this is not a requirement. Parents/guardians are welcome to attend if interested.

Yes

No

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Which session would you like to sign up for? *

Choose one (both sessions are identical).

Tuesday December 6th from 6:30 pm - 8:00 pm (Location: Rockway Community Centre)

How did you hear about this program? *

Social media

Website

Word of mouth

Flyer

Health Care Provider

Other

Would you like to subscribe to our newsletter? *

Yes

No

RELEASE AND WAIVER OF LIABILITY *

This RELEASE AND WAIVER OF LIABILITY (this "Release") is executed by the Participant (otherwise referred to as "I" or "me") in favour of Keep Your Head Up, a charity existing under the laws of the Province of Ontario, and its members, directors, officers, employees, volunteers and agents (collectively, “KYHU"). 
 I wish to participate in certain Youth Education Programming run by KYHU (the "Programming"). I understand that the Programming may include, but is not limited to, .   In exchange for being allowed to participate in the Programming and for other good and valuable consideration, the receipt and sufficiency of which I acknowledge, I hereby freely, voluntarily and without duress or undue influence, execute this Release and agree to the following terms: In exchange for being allowed to participate in the Programming and for other good and valuable consideration, the receipt and sufficiency of which I acknowledge, I hereby freely, voluntarily and without duress or undue influence, execute this Release and agree to the following terms: 1. Assumption of Risk. I acknowledge that I am voluntarily participating in the Programming and hereby expressly and specifically assume any and all risk of injury, harm, or loss that I may incur as a result of my participation in the Programming. 2. Release and Waiver. I hereby fully and forever release and discharge KYHU from, and expressly waive, any and all liability, claims and demands of whatever kind or nature, either in law or in equity, that may arise from my participation in the Programming. I agree not to make or bring any such claim or demand against KYHU, and fully and forever release and discharge KYHU from liability under such claims or demands. 3. Indemnification. I hereby agree to indemnify, defend and hold harmless KYHU from any and all liability, losses, damages, judgments or expenses, including legal fees, that it may incur or sustain as a result of my participation in the Programming, or arising out of any third-party claim. 5. Miscellaneous. I hereby agree that this Release represents the full understanding between KYHU and me and supersedes all other prior agreements, understandings, representations, and warranties, both written and oral, between us, with respect to the subject matter hereof. If any term or provision of this Release shall be held to be invalid by any court of competent jurisdiction, that term or provision shall be deemed modified so as to be valid and enforceable to the full extent permitted. The invalidity of any such term or provision shall not otherwise affect the validity or enforceability of the remaining terms and provisions. This Release is binding on and enures to the benefit of KYHU and me and our respective heirs, executors, administrators, legal representatives, successors, and permitted assigns. Section headings are for convenience of reference only and shall not define, modify, expand or limit any of the terms of this Release. 6. Governing Law. I hereby agree that this Release is intended to be as broad and inclusive as permitted, and that this Release shall be governed by and interpreted in accordance with the laws of the Province of Ontario and the federal laws of Canada applicable therein.

I have reviewed and agree to the waiver of liability form