Program Application

"*" indicates required fields

General

Program*

Age Group*

Parent/Caregiver Information

Parent/Caregiver

Name*

First Last

Address*

Street Address City Province Postal Code

Primary residence?

Is the above address the child(ren)'s primary residence?

Email*

Mobile Phone

Other Phone

Secondary Parent/Caregiver

Would you like to list a secondary parent/guardian?*

Secondary Parent/Guardian Name*

First Last

Secondary Parent/Guardian Address*

Street Address City Province Postal Code

Primary residence?

Is the above address the child(ren)'s primary residence?

Secondary Parent/Guardian Email*

Secondary Parent/Guardian Mobile Phone

Secondary Parent/Guardian Work Phone

Secondary Parent/Guardian Other Phone

Child(ren) Information

How many children will you be registering?*

First Child

Name*

Phone Number

Preferred Pronouns*

Date of Birth*

Age When Attending*

Does your child have any of the following that you feel would be beneficial for the group facilitator to be aware of?

Please provide details regarding the above selections*

Are there accommodations for your child’s condition/challenge that could help them thrive in a group setting?

Examples include fidgets, someone to help with writing, and body breaks. Please note, due to space and resources, not all accommodations may be possible but the camp facilitators will do their best to ensure all children in camp have what is needed to be fully engaged.

Does your child have any additional special needs that we should know about in order to provide a positive experience for them?

What are 2 to 3 of your child’s strengths?*

Does your child carry any of the following?

EpiPen

Inhaler

Other

If other, please specify*

Is your child able to read on their own?*

Is your child able to write on their own?*

Is there anything else you would like the facilitator to know about your child?

Media consent

I give permission for my child to appear in photographs, video, and/or audio that may be used in the promotional materials of Navera Community Connections. My child’s image may be published or used in newspapers, promotional videos, television commercials, television news items, program brochures, poster, social media sites, etc. or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by Navera. No names will ever be used in association with a child’s image without written permission of the parent/guardian. This applies to Navera at all times until removal of consent is given in writing.

Additional consent

First name use is permissible.

Mending Hearts: Children's Grief Group Intake Questions

Mending Hearts supports children who are grieving the death of a significant loved one. Please describe the relationship between your child and their deceased loved one.*

Ex. caregiver, sibling, friend, etc. and the frequency of their interactions

Describe how this loss has affected your child's well-being and behaviour at home.*

Describe how this loss has affected your child's well-being and behaviour at school.*

Ride Out The Waves Intake Questions

What symptoms of anxiety and/or worry does your child experience?*

Are you aware of specific triggers for your child’s anxiety and/ or worry?*

Ex: school, transitions, friendships, bedtime

What coping strategies have you tried? Did they work well or not?*

Finding The Warrior Within Intake Questions

What symptoms of anxiety and/or worry does your child experience?*

Are you aware of specific triggers for your child’s anxiety and/ or worry?*

Ex: school, transitions, friendships, bedtime

What coping strategies have you tried? Did they work well or not?*

Taming Worry Intake Questions

What symptoms of anxiety and/or worry does your child experience?*

Are you aware of specific triggers for your child’s anxiety and/ or worry?*

Ex: school, transitions, friendships, bedtime

What coping strategies have you tried? Did they work well or not?*

Calming The Storm Intake Questions

Describe your child's emotional regulation and behavioural strengths and challenges at home.*

Describe your child's emotional regulation and behavioural strengths and challenges at school.*

Describe your child's emotional regulation and behavioural strengths and challenges in a group setting.*

Second Child

Name*

Phone Number*

Preferred Pronouns*

Date of Birth*

Age When Attending*

Does your child have any of the following that you feel would be beneficial for the group facilitator to be aware of?

Please provide details regarding the above selections*

Are there accommodations for your child’s condition/challenge that could help them thrive in a group setting?

Does your child have any additional special needs that we should know about in order to provide a positive experience for them?

What are 2 to 3 of your child’s strengths?*

Does your child carry any of the following?

EpiPen

Inhaler

Other

If other, please specify*

Is your child able to read on their own?*

Is your child able to write on their own?*

Is there anything else you would like the facilitator to know about your child?

Media consent

Additional consent

First name use is permissible.

Mending Hearts: Children's Grief Group Intake Questions

Mending Hearts supports children who are grieving the death of a significant loved one. Please describe the relationship between your child and their deceased loved one.*

Ex. caregiver, sibling, friend, etc. and the frequency of their interactions

Describe how this loss has affected your child's well-being and behaviour at home.*

Describe how this loss has affected your child's well-being and behaviour at school.*

Ride Out The Waves Intake Questions

What symptoms of anxiety and/or worry does your child experience?*

Are you aware of specific triggers for your child’s anxiety and/ or worry?*

Ex: school, transitions, friendships, bedtime

What coping strategies have you tried? Did they work well or not?*

Finding The Warrior Within Intake Questions

What symptoms of anxiety and/or worry does your child experience?*

Are you aware of specific triggers for your child’s anxiety and/ or worry?*

Ex: school, transitions, friendships, bedtime

What coping strategies have you tried? Did they work well or not?*

Taming Worry Intake Questions

What symptoms of anxiety and/or worry does your child experience?*

Are you aware of specific triggers for your child’s anxiety and/ or worry?*

Ex: school, transitions, friendships, bedtime

What coping strategies have you tried? Did they work well or not?*

Calming The Storm Intake Questions

Describe your child's emotional regulation and behavioural strengths and challenges at home.*

Describe your child's emotional regulation and behavioural strengths and challenges at school.*

Describe your child's emotional regulation and behavioural strengths and challenges in a group setting.*

Third Child

Name*

Phone Number*

Preferred Pronouns*

Date of Birth*

Age When Attending*

Does your child have any of the following that you feel would be beneficial for the group facilitator to be aware of?

Please provide details regarding the above selections*

Are there accommodations for your child’s condition/challenge that could help them thrive in a group setting?

Does your child have any additional special needs that we should know about in order to provide a positive experience for them?

What are 2 to 3 of your child’s strengths?*

Does your child carry any of the following?

EpiPen

Inhaler

Other

If other, please specify*

Is your child able to read on their own?*

Is your child able to write on their own?*

Is there anything else you would like the facilitator to know about your child?

Media consent

Additional consent

First name use is permissible.

Mending Hearts: Children's Grief Group Intake Questions

Mending Hearts supports children who are grieving the death of a significant loved one. Please describe the relationship between your child and their deceased loved one.*

Ex. caregiver, sibling, friend, etc. and the frequency of their interactions

Describe how this loss has affected your child's well-being and behaviour at home.*

Describe how this loss has affected your child's well-being and behaviour at school.*

Ride Out The Waves Intake Questions

What symptoms of anxiety and/or worry does your child experience?*

Are you aware of specific triggers for your child’s anxiety and/ or worry?*

Ex: school, transitions, friendships, bedtime

What coping strategies have you tried? Did they work well or not?*

Finding The Warrior Within Intake Questions

What symptoms of anxiety and/or worry does your child experience?*

Are you aware of specific triggers for your child’s anxiety and/ or worry?*

Ex: school, transitions, friendships, bedtime

What coping strategies have you tried? Did they work well or not?*

Taming Worry Intake Questions

What symptoms of anxiety and/or worry does your child experience?*

Are you aware of specific triggers for your child’s anxiety and/ or worry?*

Ex: school, transitions, friendships, bedtime

What coping strategies have you tried? Did they work well or not?*

Calming The Storm Intake Questions

Describe your child's emotional regulation and behavioural strengths and challenges at home.*

Describe your child's emotional regulation and behavioural strengths and challenges at school.*

Describe your child's emotional regulation and behavioural strengths and challenges in a group setting.*

Additional Information

Has your child(ren) previously attended programs at Navera?*

Does your child(ren) have siblings that have previously used or are currently attending programs at Navera?*

Please enter sibling names*

How did you hear about this program?*

Additional Caregiver(s)

These will be the people who are allowed to collect your child(ren) or who will be called if a Parent/Guardian cannot be reached in an emergency. These contacts MUST be different than Parents/Guardians.

Your child(ren) will not be allowed to leave the Saskatoon Community Service Village with anyone not listed below. You can remove or add people to this list at any time by directly speaking with one of the program coordinators.

First Contact

First & Last Name*

Relationship to Child(ren)*

Mobile Phone*

Other Phone*

Second Contact

First & Last Name

Relationship to Child(ren)

Mobile Phone

Other Phone

Third Contact

First & Last Name

Relationship to Child(ren)

Mobile Phone

Other Phone

Release Password

Everyone picking up child(ren) will be asked for your release password or for government issued photo ID.

Release Password*

Emergency contact release consent*

I give permission to the following individuals to act as parent designates to pick up my child(ren) from this camp. I have informed these individuals that they must present government issued photo ID or that they must present a password each time they come to pick up my child(ren). I understand that in case of an emergency, I will be the first one called. However, I also give my permission to Navera to contact the following individuals AFTER contact has failed with parent designates on the front page of this registration forms.

Participants Waiver of Liability

Receipt of Information a Conditions of Service for Groups

Established in 1941, Navera Community Connections (Navera) is a family service agency that exists to transform lives by building strong individuals and families in Saskatoon and area. We are inclusive and strive to provide the highest standards of care for our clients and community. To do this we have experienced, qualified and skilled professionals who aspire to work from a hope filled, anti-racist and trauma informed framework.

Navera is committed to developing strong and healthy individuals and families by providing professional counselling, education and community programs, accessible to all.

Limits of Confidentiality

The information you give to Navera Community Connections is held private and confidential within Navera Community Connections. Information will not be obtained from or given to anyone without your written consent unless required by law, as outlined in the conditions below:

A life is in danger
A child is in need of protection

As a professional, your facilitator receives clinical supervision and peer consultation in order to maintain professional standards. In order to give you good service, your facilitator may consult with their supervisor and/or with colleagues participating in a supervision/consultation group.

Limits of Confidentiality Agreement*

I understand these limits of confidentiality.

Limits of Service

Navera Community Connections does not take a position on your behalf regarding medical/stress leaves, grievances, legal issues, or other matters involving third parties. Facilitators will not serve as witnesses in legal suits or prepare reports or other documents for legal matters.

The client agrees not to subpoena the facilitator or the facilitator's records for any legal or court report or any court appearance.

Limits of Service Agreement*

I understand these limits of service.

Conditions of Service Agreement*

I have read the conditions of service on the client information sheet and am willing to abide by these terms of agreement. I understand that my file will be held in confidence. Paper files will be destroyed after 7 years following closure.

Camp Programs

Navera takes the safety of all children registered in our programs very seriously and will take every precaution it possibly can in order to ensure the safety of your child(ren). The risk of sustaining injuries that result from the nature of the activities can occur without fault of the participant, Navera, its employees/volunteers or the facility where the activity is taking place. By choosing to take part and to register your child(ren) in Navera programs, you are accepting risk that your child(ren) may be injured. The chance of an injury occurring can be reduced by carefully following instructions at all times while engaged in program activities and by providing your child(ren) with any necessary safety equipment such as proper shoes, clothing etc.

This waiver of liability applies to Navera at all times until removal of consent is given in writing.

Sunscreen & insect repellant*

I understand that for outdoor programs I must provide a clearly labelled bottle of approved waterproof sunscreen for my child(ren) while attending. I understand that Navera staff will assist participants with the application of sunscreen as necessary.

Permission and authorization*

The above-named child(ren) has my permission to participate in program activities as planned by Navera program that I have applied for. I waive my legal rights against Navera for any loss, injury or damage suffered during or by reason of participating in all events, programs and activities scheduled while my child(ren) is in the program. I authorize the application of emergency medical attention and undertake to be responsible for any hospitalization, medical expense and ambulance expense that may be incurred.

Additional

Consent*

I consent to have my child(ren) receive services from Navera and am filling out an application for my child(ren) voluntarily. The consent will remain in effect for the duration of the program. I understand and agree to receive the program services delivered as part of the Navera program that I have applied for. Programming activities such as recreation activities and outings (field trips) involve certain elements of risk. Injuries may occur while participating in these activities.

Consent*

Are there any additional caregivers that we need to gather consent from?*

If so, we will reach out once the application is submitted to coordinate.

Yes

Application Not Registration*

I understand that by filling in and submitting this form I am only beginning the application process for this program. By filling in and submitting this form, registration is not complete or guaranteed depending on program availability, participant numbers, and more. Navera will be in touch once the application is received to continue the application process.

Comments

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