Teen Night Registration

Please note that Red Roof Retreat cannot provide 1:1 support for any teen. Typically the ratio of staff to clients at Teen Night is 1:3. Red Roof Retreat has the right to accept or deny a registration at their discretion or to send a teen home early due to health, medical or behavioural concerns.

 

Teen Night runs from 5:00pm to 8:00pm 

 

2019/2020 Dates:

Oct 8th 2019
Oct 22nd 2019
Nov 5th 2019
Nov 19th 2019
Dec 3rd 2019

Dec 17th 2019
Jan 14th 2020

Jan 28th 2020
Feb 11th 2020
Feb 25th 2020
March 10th 2020
March 24th 2020
April 7th 2020
April 21st 2020
May 5th 2020

May 19th 2020

June 2nd 2020
June 16th 2020

 

After completing and submitting this registration form please wait for confirmation from the Recreational Coordinator  before choosing and paying for your teens Teen Night dates.

 

Immediately after completing this form please email a photo of your teen to recreation@redroofretreat.com

***YOUR REGISTRATION WILL NOT BE PROCESSED WITHOUT A PHOTO OF YOUR TEEN***

 

***Payment MUST be made by the Thursday at 4pm before the session you wish to register your teen for. If this deadline is not met, you will not be able to register your teen for that program date.

 

We are unable to issue refunds without adequate notice. Cancellations must be made by 4pm on the Thursday before your teens scheduled program date.

Program Registering For (Please Check Off):

Contact Information

Country*
Email*
Confirm Email*
Phone*
Mom's Cell Phone Number
Moms Work Phone Number
Dads Cell Phone Number
Dads Work Phone Number

Registration Form

Teen's Name*
Date of Birth (DD/MM/YYYY)*
Enter Teen's Age*
Health Card Number & Letter*
Doctors Name*
Doctors Phone Number*

Emergency Name & Contact Number (other than parents):

Emergency Contact Name (1)*
Emergency Contact Number (1)*
Emergency Contact Name (2)*
Emergency Contact Number (2)*
Person Responsible for dropping off*
Person responsible for picking up*

Health Information

Diagnosis*
Please list Medications, Dosage/Time, Route:*
Behavioural Concerns*
Allergies*

Waivers

By submitting this registration form you agree to:

 

I/we the parent(s)/guardian(s) are aware of this application and are in agreement with the above application requirements (ie. payment of fees and waivers to be signed). I/we are aware of the nature of Red Roof Retreat’s programs and give consent for my/our teen to participate.

 

Photo/Video Release

I, consent to the use of any photos or videos taken of my teen during Teen Night.

 

Oath of Confidentiality

To demonstrate respectfulness to others, I/we agree to keep confidential all information concerning other children/families being served by the Red Roof Retreat/Niagara Ina Grafton Village Teen Night program.

 

Release and Indemnification

In consideration of Red Roof Retreat/Niagara Ina Grafton Village accepting within the application, I, parent/guardian of registered Teen agree to indemnify and hold harmless Red Roof Retreat and the Niagara Ina Grafton Village, its servants, agents or employees and all other organizers, sponsors, representatives and any other person or organization assisting in this Teen Night program from any claims, demands, damages, actions or causes of actions arising out of or in consequence of any loss, injury or damage to my person or my property incurred while attending at or participating in the Teen Night, notwithstanding any such loss, injury or damage that may have risen by reason of the negligence of Red Roof Retreat and the Niagara Ina Grafton Village, its servants, agents or employees and all other organizers, sponsors, representatives and any other person or organization assisting in this Teen Night program, arising out of or in consequence of the attendance or participation by our Teen at the Teen Night operated by Red Roof Retreat and the Niagara Ina Grafton Village.

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