PROGRAM PARTICIPANT ENROLMENT FORM

2015-2016 Scouting Year
P
PROGRAM PARTICIPANT ENROLMENT FORM
The purpose of gathering the information on this form is to provide Scouters with the information they need to facilitate the activities of youth participating in
Scouts Canada program activities and to be able to respond in the event of an emergency. Please note that Scouts Canada is committed to respecting the privacy of
our members, their families, and our employees, by adhering to the privacy principles set forth in Schedule 1 of The Personal Information Protection and Electronic
Documents Act. By completing this form, you acknowledge and agree to the use of your personal information as described by the Scouts Canada Privacy Statement at
myscouts.ca/ca/content/privacy-statement. This form is to be completed and signed by the parent/guardian at the beginning of each Scouting year and submitted
to the Group Commissioner. The Scouter will be provided a copy of this form and it is the responsibility of the parent/guardian to notify/update the Scouter of any
changes to the medical status of their son/daughter/ward as these changes occur. The parent/guardian should also notify the Scouter if there are any other changes to the
information on this application during the year.
Mandatory fields are marked with the symbol ‘*’
SCOUT GROUP NAME AND ROLE*:________________________________________________________________________________ Cub Scout (8-10)  Scout (11-14)
Venturer Scout (14-17) SCOUTSAbout Jr. (5-7) 
SCOUTSAbout Sr.(8-10)
Schools and Scouting (9-12)
MEMBER INFORMATION:

New Member

 Beaver Scout (5-7)
 Rover Scout (18-26)
 Extreme Adventure (14-17)
Returning Member
First Name*: ______________________________________________________________ Middle Name:_________________________________________________________
Last Name*: ______________________________________________________________ Date of Birth (mm/dd/yyyy)*:___________________________________________
Gender*:
Male Female
Evening Phone*:___________________________________________________________ Daytime Phone:_______________________________________________________
Other Phone: _____________________________________________________________ Email*:_______________________________________________________________
This email will be used as auser name in myscouts.ca if over 18 years of age
Street Address*:________________________________________________________________ City*:______________________________________________________________________
Prov/Terr*:_____________________________________________________________________ Postal Code*:_______________________________________________________________
Preferred Language: 
English

French
Are there any family circumstances, cultural or faith requirements of which the Scouter should be aware?

Yes

No
If yes, please provide details._______________________________________________________________________________________________________________________
PARENT/GUARDIAN INFORMATION: (provide at least one parent/guardian and address if different than above)
First Name*:______________________________________________________________ First Name*:__________________________________________________________ Last Name*:______________________________________________________________ Last Name*:__________________________________________________________
Date of Birth (mm/dd/yyyy): ________________________________________________ Date of Birth (mm/dd/yyyy): ___________________________________________
Evening Phone: ____________________________________________________________ Evening Phone: _______________________________________________________
Daytime Phone:___________________________________________________________ Daytime Phone:_______________________________________________________
Other Phone:______________________________________________________________ Other Phone:_________________________________________________________
Email**:__________________________________________________________________ Email*:______________________________________________________________
Street Address:____________________________________________________________ Street Address:________________________________________________________
City:_________________________________________Prov/Terr:___________________ City:_______________________________________ Prov/Terr:________________
Postal Code:________________________ Country:______________________________ Postal Code:_______________________ Country:_________________________
Email**: This email will be used as the parent/guardian’s user name in myscouts.ca if participant is under 18 years of age.
ALTERNATE EMERGENCY CONTACT INFORMATION: (provide at least one emergency contact in addition to parent/guardian above)
Emergency Contact 1*:
Emergency Contact 2:
Emergency Contact 3:
Last Name*:__________________________________
Last Name:___________________________________
Last Name:___________________________________
First Name*:__________________________________
First Name:___________________________________
First Name:___________________________________
Daytime Phone*:______________________________
Daytime Phone:_______________________________
Daytime Phone:_______________________________
Evening Phone*:_______________________________
Evening Phone:________________________________
Evening Phone:________________________________
Other Phone:__________________________________
Other Phone:__________________________________
Other Phone:__________________________________
Relationship to member*:_________________________
Relationship to member:__________________________
Relationship to member:__________________________
Permission to pick up youth from meetings*:
Permission to pick up youth from meetings:
Permission to pick up youth from meetings:
 Yes
 Yes
 Yes
 No
Youth Program Participant Enrolment Form
 No
Page 1 of 2
 No
2015-2016 Scouting Year
Applicant Last Name:___________________________________________________ Applicant First Name:___________________________________________________
MEDICAL EMERGENCY PROCEDURES CONSENT:
Residents of all Provinces/Territories except Quebec: Experience has shown
that in connection with Scouting activities there are times when illness
or accident may occur and immediate surgical or medical attention is
necessary. This is my permission for the Scouter in charge, or designate, to
make arrangements for qualified surgical or medical attention for my son/
daughter/ward in the event of an emergency without necessity of my prior
approval. I understand that I will be notified by the quickest means possible if
this authority is exercised.
Residents of Quebec:
Experience has shown that in connection with Scouting activities there are
times when illness or accident may occur and immediate surgical or medical
attention is necessary. In the event of an emergency in which my child’s life is
in danger or his/her integrity is threatened and I cannot be reached to provide
consent, I agree that care may be provided to my child without my consent,
as contemplated in paragraph 1 of article 13 of the Civil Code of Quebec.
I understand that I will be notified by the quickest means possible if this
authority is exercised.
INFORMATION FOR MEDICAL EMERGENCIES:
Provincial/Territorial Health Care Number (Voluntary in some provinces and territories):_______________________________________________________________
Physician’s Name:__________________________________________________________ Physician’s Phone:__________________________________________________
Insurance Coverage Held (Voluntary in some provinces and territories)*: Does the participant have any allergies?* 
Yes
Yes
No__________________________________________________________________
No If yes, provide details below indicating severity (mild, severe, life threatening):

Please advise of any medical conditions, diseases, operations, disorders or problems the member has had or currently has below.
Does the participant require special care, medication or diet? If yes, please provide details below*: 
Yes
No

_____________________________________________________________________________________________________________
Date of last tetanus shot (Month and Year):_______________________________________ Swimming Abilities: Non Swimmer Swimmer
PHOTO RELEASE,FUNDRAISING AND COMMUNICATIONS CONSENT:
Throughout the Scouting year, leaders, parents and Scouts Canada employees take photos and video of youth participating in Scouting activities. These photos are
typically kept in Group photo albums and displayed on Group web sites. Some are also submitted to local newspapers and to Scouts Canada’s Communications
Services where they are often used in Scouts Canada publications and promotional materials.
 Tick this box if you DO NOT consent to the use of images of yourself and/or your son/daughter/ward as indicated above.*
 Tick this box if you wish to be informed about fundraising and other member benefits not specifically related to your Scouting program.*
 Tick this box if you wish to receive relevant and timely information about your Scouting program from Scouts Canada via email or mail.*
PARENT/GUARDIAN INVOLVEMENT:
Your VOLUNTEER Scouters need your assistance in the operation of your child’s program. We know that parents/guardians enjoy participating with their
son/daughter/ward and Scouts Canada encourages this. Please feel free to tick off one or more of the boxes below indicating areas in which you would be interested
in providing assistance.







Full-time Scouter/Parent Volunteer
Communications
Environment & Nature Lore
Part-time Scouter/Parent Volunteer
Organization & Planning
Outdoor Activities
Committee Administration







Cooking, Banquets
Singing, Music
Resource Person
Drawing, Art
Sports
Camp Helper
Drama, Skits, Play Acting







Woodworking
Phoning
Games
Science/Engineering Activities
Fundraising
Handicrafts
Other: ________________________________
INFORMATION UPDATE: Note: parent or guardian must sign the Consent to Participate section at the bottom of this form. This section is to be signed by the parent
or guardian when there are updates during the Scouting year.
Updated By(Parent Name):_______________________________________ Signature:__________________________________________ Date:____________________
(Please Print)
(mm/dd/yyyy)
Updated By(Parent Name):_______________________________________ Signature:__________________________________________ Date:____________________
(Please Print)
(mm/dd/yyyy)
Updated By(Parent Name):_______________________________________ Signature:__________________________________________ Date:____________________
(Please Print)
(mm/dd/yyyy)
CONSENT TO PARTICIPATE:
To be completed if the Applicant is under 18 years of age. I understand
that participation in Scouts Canada is voluntary, and involves a certain
degree of risk when participating in some Scouting activities. After
carefully considering the risks involved, and having full confidence that
reasonable precautions will be taken to ensure the safety and well-being of
my (son/daughter/ward), I grant permission for my son/daughter/ward, to
become a member of Scouts Canada and participate fully in its activities.
X
__________________________________________________________________________________________________________________
Signature of Parent/Guardian
Date (mm/dd/yyyy)
To be completed by Rover Scouts 18 years of age and over I will subscribe
to the Mission, Principles, Practices and Methods of Scouts Canada. I
will abide by the By-Laws, Policies and Procedures of Scouts Canada. I
understand that participation in Scouts Canada is voluntary and involves a
certain degree of risk when participating in some Scouting activities. After
carefully considering the risks involved, I will take, to the best of my ability,
reasonable precautions to ensure the safety of other members (youth and
adult) as well as my personal safety. I have or I will have, read, understood,
agreed to and signed the Code of Conduct, and I will abide by the Code of
Conduct as a condition of membership.
X
______________________________________________________________________________________________________________
Signature of Parent/Guardian
Date (mm/dd/yyyy)
Note to Scouters: At the end of the year, please forward your copy of this form to your council office.
* mandatory fields
Youth Program Participant Enrolment Form
Page 2 of 2