North BurLINKton » Chill Zone Registration

Chill Zone Registration

Chill Zone is a free drop-in program in North Burlington.

Please provide the following information so that we can contact you if there is an emergency.

(year/month/day)
(easiest to reach you at during the day)
If No, please tell us who will pick them up
Please let us know if your child has a medical condition or allergies that we should be aware of

Photography/Film/Video/Social Media/Audio Recording Release Form

I hereby authorize Community Development Halton (“CDH”), through its employees, agents, and/or representatives to photograph, film, video, or use my voice and/or likeness in CDH promotions. I grant to CDH the right to use, publish and display or permit the use, publication and display of any likeness of me, including in the form of negatives, slides, prints, photographs, videos and other depictions of me, in any medium whatsoever in which the images may appear. I acknowledge that I am not entitled to any form of payment for the use of my likeness or for any future photo, film or video publications. I also agree to waive any and all future claims, causes or actions and/or demands against CDH, its Board of Directors, officers, employees, agents and/or representatives related to or arising from the use of my likeness in CDH publications. My signature on this document acknowledges that I have read and understand the above provision and agree to abide by these terms. By signing this form, I confirm to have read, understood and consent to the above. I am of legal age in my province/territory of residence, or have had my parent/legal guardian sign below on my behalf.

(year/month/day)
FOR MINOR SUBJECT (under the age of 18 yrs.)
(print camper's full name)

Leave a Reply

%d bloggers like this: