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Strong is Beautiful Registration Form

The Huron-Kinloss Community Services Department is excited to work with Fitness Instructor Melissa Dozois for a new program for Young Girl Teens age 12-14 who want to develop a healthy relationship to their body and mind.

During each session, the girls will learn a new physical skill... strength training, flexibility, and cardiovascular training using a variety of tools including the TRX, Spin Bikes, Free weights, Slam Balls, Yoga, and Mobility/Flexibility Work.

Mindfulness will also be an important aspect to each session. Learning how to deal with stressful situations (mentally and physically), staying calm and in the present moment will be developed through various mindfulness based techniques.

Program will include health eating, meditation, mindfulness and safe fitness workouts, using the Huron-Kinloss Community Services exercise equipment.

For more information, contact Recreation Department at recreation@huronkinloss.com or 519-395-2909.

Registration online today - spaces is limited!

Participant Name

Participant's Date of Birth

Parent's Name

Address (including postal code)

Phone Number

Email Address

Emergency Contact Name

Emergency Contact Phone Number

Relationship to Family

Assumption of Risk and Indemnifying Release

While Township of Huron-Kinloss staff and volunteers will make every reasonable effort to minimize exposure to known risks associated with each Registrant’s participation in a Township of Huron-Kinloss program (“Program”), I hereby acknowledge that I and/or my child if I am registering on his/her behalf (collectively, the “Registrant”) may be required, depending on the nature of the program, to participate in various physical activities that may involve a risk of injury. In this regard, I hereby permit the Registrant to participate in the full range of Program activities. In consideration of the Registrants opportunity to participate in the Program, the receipt and sufficiency of which is hereby acknowledged, I hereby release and hold harmless the Township of Huron-Kinloss, its respective officers, directors, employees, volunteers and agents, and their respective successors and assigns from any and all liability for damages sustained in consequences of loss, injury or damage to the Registrant, and from all other actions, causes of action, claims, demands or damages of any kind with respect to death, injury, loss or damages to any person or property arising out of or connected with preparation for, or participation in, the Program.

REGISTRATION AGREEMENT By signing my name, I (or my legal guardian) acknowledge that I (or we) have carefully read and understand the, Assumption of Risk and Indemnifying Release Statement, Medical Emergencies Statement and Disclaimer.

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Registration Agreement Date:

I consent to receiving class cancellation notices via text

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Physical Activity Readiness Questionnaire (PAR-Q)

* Please be aware that all information on completed forms will be confidential

As promoters of health lifestyle, we're concerned about your well being when participating in our programs. To help identify the type of activity, which is most suited to each individual, we are asking you to complete a PAR-Q as part of the program. This questionnaire is designed to identify individuals for whom an increased physical activity might be in appropriate or those who should seek medical attention prior to program commencement.

Please read carefully and answer Yes or No to the following questions:

Has your family doctor said that you have heart trouble?

Do you frequently have pains in your heart or chest?

Do you often feel faint or have dizzy spells?

Has your doctor ever said your blood pressure was too high?

Has your doctor ever told you that you have a bone or joint problem such as arthritis, which has been aggravated by exercise or might be made worse with exercise?

Are you unaccustomed to a steady increase in your physical activity level?

Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to be?

Do you take medication on a regular basis (heart, asthma)? If yes, please list the medication name:

If you answered "Yes" to any of the above questions, you should consult your physician before increasing your physical activity level.

Participant's Signature/Legal Guardian's Signature

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PHOTO AND VIDEO CONSENT AND RELEASE

By signing this form, you are consenting to the taking of photographs and/or video recordings of you by the Township of Huron-Kinloss for the purposes of marketing and promoting programs. You are assigning to the Township of Huron-Kinloss and waiving any rights you have related to any photographs and video recordings and you are consenting to the use of such photographs and/or video recordings, in whole or in part, by the Township of Huron-Kinloss. I hereby agree to allow photographs and/or video recordings to be taken of me, whether posed or candid, while I am on Township of Huron-Kinloss property and/or participating in Township of Huron-Kinloss programs.

ASSUMPTION OF RISK AND INDEMNYFING RELEASE
While Township of Huron-Kinloss staff and volunteers will make every reasonable effort to minimize exposure to known risks associated with each Registrant’s participation in a Township of Huron-Kinloss program (“Program”), I hereby acknowledge that I and/or my child if I am registering on his/her behalf (collectively, the “Registrant”) may be required, depending on the nature of the program, to participate in various physical activities that may involve a risk of injury. In this regard, I hereby permit the Registrant to participate in the full range of Program activities. In consideration of the Registrants opportunity to participate in the Program, the receipt and sufficiency of which is hereby acknowledged, I hereby release and hold harmless the Township of Huron-Kinloss, its respective officers, directors, employees, volunteers and agents, and their respective successors and assigns from any and all liability for damages sustained in consequences of loss, injury or damage to the Registrant, and from all other actions, causes of action, claims, demands or damages of any kind with respect to death, injury, loss or damages to any person or property arising out of or connected with preparation for, or participation in, the Program.

DISCLAIMER
All programs are subject to change or cancellation due to low enrolment numbers, lack of volunteers or other unforeseen circumstances that are prohibitive to the operations of the program.

MUNICIPAL FREEDOM OF INFORMATION AND PRIVACY ACT
In accordance with the Municipal Freedom of Information and Privacy Act, personal information is collected under the Authority of the Municipal Act, R.S.O. 1990, c.M45, as amended, and will only be used for the purpose of maintaining adequate records of participation and enrollment in recreation programs and for medical information when required in emergency situations.

RECREATION AND PROGRAMMING SUBSCRIPTION
I would like to subscribe to The Township of Huron-Kinloss distribution lists regarding any future recreation and programming notifications.

By signing here, I agree to all listed in the previous question:

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