Home > MAD Mondays – Youth Registration MAD Mondays – Youth Registration A registration form for the weekly M.A.D. Monday after school program for youth offered by MDAM. Participant DetailsYouth Name(Required) First Last Age(Required)Date of Birth(Required)Enter the date you were bornParent/Guardian Information:Parent/Guardian Name:(Required) First Last Parent/Guardian Email(s):(Required)Parent/Guardian Phone(s):(Required)Emergency Contact InformationEmergency Contact Name:(Required)Emergency Contact Phone Number:(Required)Emergency Contact Relationship to Youth:(Required)Participant Background:Do you have any allergies? If yes, please describe:(Required)Do you have any dietary restrictions? If yes, please describe:(Required)Do you have any mental health concerns we should be aware of? If yes, please describe:(Required)Is there any other information you would like to share with us that is useful for staff to know while supporting you? If yes, please describe:(Required)Consent and PermissionsMedia Consent I consent to take video or photo content of my child (as it relates solely to M.A.D. Mondays and its activities) and share it across the organization’s channels.Media Consent: I, the undersigned, hereby consent to the use of my child’s photograph or likeness in any publication, videotape, pamphlet or promotion by Mood Disorders Association of Manitoba, or other agencies which are promoting or furthering the mission of MDAMParent/Guardian Signature: First Last Youth Signature: First Last Date MM slash DD slash YYYY Media Non-Consent I do not consent to the sharing of any photos, videos, or promotion containing the image of my childParent/Guardian Signature: First Last Youth Signature: First Last Date MM slash DD slash YYYY Peer-Support Consent This is intended to confirm a parent’s permission for their child to receive peer support from Mood Disorders Association of Manitoba – their coordinators, camp counsellors or volunteers, – in a 1on1 or peer support group setting.Please be advised that all information is kept with the strictest confidence. Mood Disorders Association of Manitoba adheres to the confidentiality guidelines as outlined in FIPPA and PHIA. The coordinators, volunteers, peer support workers and camp counselors at Mood Disorders Association of Manitoba will not disclose, share or reveal any information learned in a 1on1 or group peer support session unless it involves either of the following: • Disclosure of any acts of harm, injury or abuse directed at the child or other children in the home (whether the disclosure is of an historic or current nature). • Disclosure of a camper’s intentions to harm oneself or others. In these circumstances, the adult is responsible for disclosing the abuse to an appropriate agency and contacting professionals, due to the child’s safety. Peer Support Consent: I, the undersigned, hereby consent to my child receiving peer support from MDAM. I understand that I cannot be told any information that is relayed during a 1on1 or group peer support session, except within the limits of confidentiality. Parent/Guardian Signature: First Last Youth Signature: First Last Date MM slash DD slash YYYY Non-Consent I do not consent to my child receiving/participating in 1on1 or group peer support sessions. I ask MDAM to not provide any peer support to my child, aside from general camp direction and facilitation.Parent/Guardian Signature: First Last Youth Signature: First Last Date MM slash DD slash YYYY Consent to attend MAD Mondays I have read and understand the questions above and allow my child to participate in M.A.D. Monday’sParent/Guardian Signature: First Last Youth Signature: First Last Date MM slash DD slash YYYY Please be advised all information will be kept in stricted confidence. MDAM adheres to the guidelines as outlined in the Freedom of Information and Privacy Act (FIOPPA), the Personal Health Information Act (PHIA), and the Personal Information Protection and Electronic Documents Act (PIPEDA).
