JUNIOR CREATING CONFIDENCE WORKSHOPAny additional questions or concerns regarding this program, please email shawn@blindbeginnings.ca. Child's Name * First Name Last Name Date of Birth MM DD YYYY Visual Impairment Diagnosis Additional medical information we should be aware of: Any special dietary requirements or allergies? Email address to send Zoom link for virtual component (if different from Parent email) Parent's Name * First Name Last Name Parents Phone Number * (###) ### #### Parent's Email * Person who will be picking up child at the end of the workshop (if different from parent listed above) By selecting the following, I hereby give my consent for my child to attend Junior Creating Confidence * I agree PHOTO RELEASE - I hereby consent for my minor child/wards to be photographed by or for Blind Beginnings with the understanding that the photos will be used for teaching and/or future program public relations. I understand that these photos may be used in our Blind Beginnings brochure, newsletter, annual report and on promotional banners, and/or photos and video may be shown during presentations to potential donors, and/or available on the Blind Beginnings website, Blind Beginnings Facebook, LinkedIn, and Instagram pages, or on our Blind Beginnings YouTube page. Yes No As part of the program we may be travelling to a local restaurant for dinner, which will involve travel on foot or transit. Click below to indicate your consent for your child/ward to attend this dinner. I agree I do not agree Any additional questions or comments Thank you! Your information has been submitted and you are registered for this Junior Creating Confidence Workshop.
