8/2/2019 CitizenU - Promotion & Registration Package

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Kitsilano Neighbourhood House has partnered with the City of Vancouver to host

CitizenU, a powerful program on anti-racism, anti-discrimination, and

community building. The program is for youth ages 15-20, is FREE and includes

food and bus tickets.

PHASE 1: Training Workshop April 29

PHASE 2: City-Wide Events June & July

PHASE 3: Action Team Projects August-October

Throughout the project you will get to meet diverse youth from across the city

who also want to reduce discrimination and promote community building.Kitsilano Neighbourhood House and CitizenU will support your events and

projects to help build bridges between communities.

You will gain leadership skills that you can apply to your everyday life and learn

by action, not by sitting and talking! You will also leave the program with a large

network of peers and adult allies that you can work with over the coming years.

School credits are available for participation and you’ll receive a certificate. 

Youth Anti-Discrimination Training

8/2/2019 CitizenU - Promotion & Registration Package

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Want to Register or Find Out More?

Contact Zsuzsi Fodor at Kitsilano

Neighbourhood House

zsuzsi@kitshouse.org

604-736-3588 ext. 313686 West 4

thAvenue (2

ndFloor)

Tuesdays & Thursdays

CitizenU Online 

CitizenU Video 

Kitsilano Neighbourhood House Online 

REGISTRATION DEADLINE: April 20

Submit Forms by E-Mail*, Mail or In Person*scanned copy with signatures

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CitizenU Registration Form

Youth Information:

First Name: Last Name:

Home Phone #: Email:

Address:

School: Age & Grade:

Emergency Contact Information:

Emergency Contact Name: Relationship:

Work Phone #: Home Phone #:

Cell Phone #:

Medical Information:

Medical Number: Doctor’s Phone #:

Doctor’s Name: Are you taking any medications?

What allergies do you have? Name of medication:

I, (parent of guardian name), give permission for my son/daughter,, (youth’s name) to attend Kits House Youth Programs. I understand that transportation on out trips will be by:walking, private van, and by public bus / sky train. I/we agree that my son / daughter will follow all reasonableinstructions and directions of the leaders and instructors duly appointed by Association of Neighbourhood Houses(ANH) in connection with the operation of the Kitsilano Neighbourhood House program as described in the programbrochure. I / we herby release, remise and forever discharge Kitsilano Neighbourhood House and ANH, it’s agents or volunteers, of and from all manner of actions, cause of action, claims and demand of whatever nature which resultsfrom any injury, loss or expense sustained, arising out of or in any way connected with participation in any program orattendance at any location operated by ANH. In the event that our son / daughter are injured, ill or in need of medicalattention and I am unable to be contact, I authorize ANH staff to seek medical attention on my behalf.

(Parent Signature) (Date)

Privacy:Kitsilano Neighbourhood House and the Association of Neighbourhood Houses respect your family’s personal privacy. Theinformation collected on this form is in complication with the BC Personal Information Act and is used to process the programregistration, help care for the safety and well being of program participants, to provide your family on future events and programs atKNH and to gather information on our progams and program use. This general information will be provided to our funders. If youhave any questions or would like a copy of the ANH Privacy Act Policy, please contact Zsuzsi Fodor zsuzsi@kitshouse.org. 

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CitizenU: PHOTO PERMISSION RELEASE FORM

Dear Youth/Parent/Guardians,

During the course of the CitizenU Project participants may be photographed for the

purpose of maintaining memories for Kitsilano Neighbourhood House (ex. newsletter,website or slideshow).

Therefore Kitsilano Neighbourhood House would like to ask permission to use photos

for promotional purposes. If this is acceptable please sign this release form and return it

to the program facilitators. However, if you would prefer that we do not use any photos

for promotional purposes then please indicate it on the form below.

Thank you for your time & support!

Kitsilano Neighbourhood HouseCitizenU Photo Release Form

I hereby acknowledge in the course of the CitizenU Program I/myson/daughter may be photographed for the purpose of maintainingmemories and documenting the program process.

I give permission for Kitsilano Neighbourhood House to take or use photos

 I DO NOT give permission for Kitsilano Neighbourhood House to take or use photos

 _____________________________________ Date

 ______________________________________________________________________ Parent Guardian Name (if youth under 18) Signature