ASSAI Participant Information Form

Please complete the following form before your child’s first day of ASSAI. If you completed this form already for this school year (2024-2025) you do not need to complete the form again.

Information and Emergency Contact Form

"*" indicates required fields

Participant Information

Child's first name*

Child's last name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Primary language spoken at home:*

Does your child identify as indigenous?*

Yes

Gender at birth*

Male

Female

Gender identity (if applicable)

Male

Female

Non-binary

Transgender

Other

Personal pronouns

She/Her

He/Him

They/Them

She/They

He/They

Tell us a bit about your child

Does your child have any diverse needs (behavioural, social) or disabilities we should be aware of?

Does your child have any allergies?*

Yes

Please describe the allergies, their severity and if medication is required.

Does your child have any other medical conditions?*

Yes

Please describe the medical condition and ways to support your child.

Please let us know if your child is on any medication for their medical condition.

Are any custody orders or agreements in place?*

We request this information in case there are pick-up agreements in place that the Centre should be aware of.

Yes

Please describe the custody order or agreement and specify any pick up arrangements.

If a custody order is in place, we will require a copy of the order.

Does your child have permission to walk home on their own after ASSAI (Grades 3-5 only)?*

Yes

Is your child in After School Care?*

Yes

Parent/Guardian Information (Main Contact)

First name*

Last name*

Relationship*

Mother, father, guardian, etc

Same address as child?*

Yes

Address (if different from child)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone*

Parent/Guardian Information (Secondary Contact)

First name

Last name

Relationship

Mother, father, guardian, etc

Same address as child?

Yes

Address (if different from child)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Emergency Contact Information

Please provide at least one emergency contact not already listed above. Note that aside from their parents/guardians, participants will only be released to people listed as emergency contacts. Contact the coordinator to make changes to your list at any time. All emergency contacts must by 19 years or older.

#1: First name*

#1: Last name*

#1: Phone*

#1: Relationship*

#2: First name

#2: Last name

#2: Phone

#2: Relationship

#3: First name

#3: Last name

#3: Phone

#3: Relationship

Medical Permission

If a situation should arise where it is deemed necessary to obtain immediate medical attention and staff are not able to reach parents/guardians, staff will transport your child to the nearest emergency treatment centre or contact an ambulance on your child’s behalf. Emergency services will be provided with a copy of your child’s health information. I authorize the staff of the James Bay Community School Centre Society, in the event of an accident or illness requiring emergency treatment affecting my child, to authorize on my behalf all procedures, including admission to hospital and any necessary treatment therein as he/she may deem essential for the care and well-being of the child. Such action is only to be taken when immediate contact with the undersigned cannot be made. It is understood that the JBCSC is not responsible for medical care or ambulance costs.

Yes

Photo Release

In accordance with the BC Freedom of Information and Protection of Privacy Act (FOIPPA), the James Bay Community School Society is seeking your consent to collect, keep, use and share photographs and/or videos of your child in a variety of publications, reports, Centre displays, and the JBCSC website. I understand that images posted on the internet may be stored and accessed outside of Canada. Ex: images may be used or shared in newsletters, brochures, and reports in limited circulation in addition to websites and social media platforms with limited or public access. The JBCSC is committed to respecting your privacy and will abide by any restrictions indicated above in using your photograph and video footages accompanying personal information. Your personal contact information will not be shred without your consent. I authorize the JBCSC and approved third parties to use photos/videos of my child for in-Centre use, including, but not limited to newsletters, bulletin board displays, photo albums, commemorative items and reports.

Yes

Parent/Guardian Consent*

In permitting my child to attend the ASSAI program at James Bay Community School Centre, I release and discharge any and all rights and claims for damages and causes of suit or action that I or my child have at any time against the James Bay Community School Centre Society, along with their employees or agents; for any and all injuries or losses suffered by my child as a result of participating in the James Bay Community School Centre programs.

I agree

I do not agree

James Bay Community School Centre Privacy Policy

Get in touch with us!

Registration & Info Line:
250-389-1470

Recreation Program Registration:
You can register for classes over the phone, at the Centre desk, or online!

Please note our new policy as of December 11, 2023: There is now a non-refundable administrative fee of $2 added to all program registrations whether they are done online, over the phone or in person. This is to help cover the transaction fees charged to the JBCSC by our registration software provider.

To Register online click here

Simply click on the categories to explore. Select what you would like to register for and system will prompt you to log in or create an account.

If your child has been registered in Childcare, you may already have an account.

Please try the log in option first.

Childcare Registration:
Click here to read about our childcare programs and to let us know that you are interested!

Refund Policy:

Refunds will only be issued for withdraw requests made three business days in advance of the class start.

If after attending the first class you decide a program is not right for you, we are happy to issue a pro-rated refund. This request must be made at least a day prior to the start of the second class.

Refunds will generally not be issued for withdrawal after the second class. Special circumstances may be considered and may require a note from a medical professional.

Please note that the non-refundable administrative fee of $2 will not be refunded if you withdraw from a program, but it will be refunded in the event that the JBCSC has to cancel a program.

L.I.F.E Program Subsidies:
The L.I.F.E. program provides a combination of annual credit and program savings to eligible individuals and families. You can find more information here.

Interested in Offering a Program?

We are always interested in offering new programs! If you have a suggestion or want to teach a program or workshop, please visit our Recreation Program Proposal page.

Find Us

Address
140 Oswego St, Victoria BC V8V 2B1

Hours
September to June

Monday—Friday: 9:00AM–5:00PM (some nights we are open until 9:00pm)
Sunday: 9:00AM–1:00PM

July and August

Monday—Friday: 9:00AM–5:00PM

ASSAI Participant Information Form