Please fill in all applicable spaces to the best of your ability. You must be between the ages of 12-18 years old to attend LCYC!
Emergency Contact Information(other than parent/guardian)
I, the parent/guardian of the above mentioned youth acknowledge the risks associated with my child participating in any events, programs, and activities scheduled with the Lloydminster Community Youth Centre (LCYC), a division of the Lloydminster Interval Home Society (LIHS). LIHS is legally responsible to contact Child & Family Services if there are concerns for your child's safety or well-being. This includes information that is disclosed to staff by youth.
Please check off to indicate consent on the following: