Mindfulness for Youth Registration form

Parent/Guardian Name*

First Last

Email

Youth Name*

First Last

Youth Date of Birth*

This program is open to youth in grades 9-12 (or equivalent age).

Youth's prefered pronouns*

Male
Female
Gender Neutral

Is the youth:

part of LGBTQ communities
a person of colour
living with a disability

Would you like to register another youth?*

Yes
No

Second youth's name*

First Last

Second Youth's Date of Birth*

Second Youth's prefered pronouns*

Male
Female
Gender Neutral

Second youth

Is the youth:

part of LGBTQ communities
a person of colour
living with a disability

Additional information

Any allergies, medication, medical conditions, abilities, special needs, learning disabilities, health, emotional needs, family situation, etc. that may affect participation in the program. Sensitive information will be kept confidential and will be made available only to program facilitators, as needed. If you prefer to discuss by phone please include a phone number and best times to reach you.

Photo Permission*

We would love to take a few pictures to share in our promotional materials, but we require your informed consent and agreement before we do so. Here are the details: I/we grant permission to First Unitarian Church of Victoria (FUCV) to take photographs and/or videos of my child(ren) when participating in this program. I/we understand that our child(ren) will not be identified by name. I/we authorize FUCV and the Canadian Unitarian Council (CUC) to use the likeness(es) of my child(ren), in print or electronically, for lawful and reasonable purposes including church displays, congregational and CUC communications, and on the FUCV and CUC websites.

Yes
No
Please contact us to discuss this further

Are you or your family members of First Unitarian Church of Victoria?*

There is no charge for participation for members of FUCV. The fee for non-members is $25, however, a reduction can be made if this is a barrier to participation.

Yes
No

Would the $25 fee be a barrier for your family?

Yes
No
Unsure

Fee reduction

If you would like to apply for a reduction in fees please briefly describe below. If you would prefer to discuss by phone please include your number and good times to call.

How did you finf out about this program?*

Mindfulness for Youth Registration form

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In a spirit of gratitude and respect we acknowledge the traditional land of the WSÁNEĆ First Nations, on whose lands we gather.