Q1 .     Student's First Name

Q2 .     Student's Last Name

Q3 .     Student's Age

Q4 .     Student's Gender

Q5 .     Student's First Language (mother tongue)

Q6 .     Please list the student's PR number below.

Q7 .     Name of student's school

Q8 .     Student's email

Q9 .     Student's cell number

Q10 .     Home Address (number, street, city, province and postal code)

Q11 .     Parent/ guardian first name

Q12 .     Parent/ guardian last name

Q13 .     Parent/ guardian phone number (cell or home)

Q14 .     Parent/ guardian email

Q15 .     Emergency contact Name (First and Last Name)

Q16 .     Emergency contact phone number (cell or home)

Q17 .     I understand that my child will need to use two-way video to participate in this program (their video camera has to be turned on).

Q18 .     I understand that this program runs every Thursday, beginning on October 20, 2022 from 3:30PM to 5:00PM and confirm that my child will be present at all the sessions (if child is sick please notify us in advance)

Q19 .     USE OF PERSONAL INFORMATION FOR PROGRAM REGISTRATION I consent to having the information on this form used for the purposes of registering my child in the CommuniCreate program. I understand that the information on this form is collected under the general authority of the University Act (R.S.B.C. 1979, c.419). It is related directly to and needed by the University for registration to the CommuniCreate program. The information will be used to determine eligibility for the program, to track program registrants, to ensure the health and safety of students, to provide the best service to students as possible, and to track/report out on the success of the program. If I have any questions about the collection and use of this information, I know that I can contact the Associate Director, Partnerships and Programs: 13450 102 Avenue, Surrey BC, V3C 6M8; 778-782-8082.

Q20 .     PROGRAM EXPECTATIONS AND ASSUMPTION OF RISK. I consent to and am aware of the following while participating in programs offered through the SFU Surrey – TD Community Engagement Centre: 1. I understand that the program is meant to provide learning and social development opportunities, but is not a formal educational program. Program facilitators / leaders are not professional teachers or educators. 2. I understand that this program is a weekly commitment and I will support my child’s participation for the duration of the program. 3. I understand that my child will be participating in this session virtually from home and needs access to a computer or tablet and internet during the program hours. 4. I understand that the sessions take place using a program called Zoom which uses two-way video. The program facilitators will be able to see the child and the child will be able to see the facilitators. For privacy, you have the option to use a nickname for the child and to put up a virtual background (wallpaper) so that no one can see into your home. Program facilitators will review how to do this at the beginning of the first session. 5. My child will respect the staff/volunteers and other students participating in the program. Failure to act appropriately may result in the loss of the privilege of attending the program. 6. I understand that the program may collect information from students or teachers for basic evaluation purposes to ensure continuous improvement of the program. 7. I hereby release, indemnify and hold harmless Simon Fraser University and any other organizations involved in program delivery, their officers, officials, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the program, from any and all claims, demands, losses, and liability arising out of or related to any injury, or loss or damage to person or property, to the fullest extent permitted by law.

Q21 .     Would you like to sign up for our newsletter? The newsletter will be sent to you by email to update you on SFU programs that might be of interest to you and your family.

Q22 .     How did you hear about this program? (eg: Email, Social Media, Community Organization)