Informed Consent & Permission FormParks, Recreation and Culture
6911 No. 3 Road, Richmond, BC V6Y 2C1THIS IS AN IMPORTANT DOCUMENT. PLEASE HAVE SOMEONE TRANSLATE IT FOR YOU.
CE DOCUMENT EST IMPORTANT, VEUILLEZ LE FAIRE TRADUIRE.

Communicable Disease Prevention Plan
Informed Consent & Permission FormBY SIGNING THIS DOCUMENT, YOU AND YOUR CHILD’S LEGAL RIGHTS MAY BE AFFECTEDPLEASE READ CAREFULLY!
We are operating our facilities in accordance with the City of Richmond’s Communicable Disease Prevention
Plan (CDPP), a guide that provides important information required to help prevent communicable diseases in City
workplaces and facilities. As such, we are permitting user groups access to our facilities on the basis that CDPP
guidelines will be adhered to by user groups and individual participants. Safety of staff and the community is ourpriority.
It is important that that no person who is feeling unwell with symptoms consistent with a communicable disease
visits any of our facilities and/or utilize any of our services. It is also important that no person brings a child whofeels unwell or is showing any symptoms consistent with a communicable disease to any of our facilities and/orprograms.
Please Note: If your child is displaying symptoms of respiratory distress or illness, they will be asked not to participate.
A communicable disease is an illness caused by an infectious agent or its toxic product that can be transmitted ina facility from person to person through bodily fluids or discharge, contaminated surfaces or objects. Examples ofthe more common communicable diseases that may circulated include COVID-19, norovirus, and seasonal
influenza.
Communicable
DiseaseCommon Symptoms

COVID – 19

Fever, cough, flu-like symptoms, shortness of breath and breathing difficulties

Influenza

Fever, cough, sore throat, runny or stuffy nose, muscle/body aches,headaches, fatigue, sometimes vomiting and diarrhea

Norovirus

Diarrhea, vomiting, nausea, stomach pain, fever, headaches, body aches

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City of RichmondInformed Consent and Permission Form

We will emphasize hygiene and provide for handwashing in our programs. However, it is vital that registrants bepermitted to play and this includes games where there will be touching (such as tag) and use of playgroundequipment.
It is vital that we all be calm and compassionate and uphold the Respectful Environment Code of Conduct
requirements when using City of Richmond facilities. Any person who exhibits any aggression towards our staff or
any other person in one of our facilities and/or programs will be asked to leave and not return.

INITIAL HERE

I/we have read, understand and agree to the Informed Consent and Permission Form.
INITIAL HERE

I/we have reviewed the Informed Consent and Permission Form with my/our child and have
instructed our child to listen to and follow the instructions provided.

Name of Child:

Date:

Signature of Parent/Guardian:Printed Name:

Signature of Parent/Guardian:Printed Name:

Email:

Phone:

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City of RichmondInformed Consent and Permission Form

Please PRINT all information & fill out all applicable sections completely. Pleasesubmit this form prior to the start of program.
A. PERSONAL INFORMATION: (please ensure all phone numbers can be reached during program)Participant’s Name:
Date of Birth:Age:Parent/Guardian:

Phone:

Parent/Guardian:

Phone:

Email:In case of emergency, please contact: (other than parent/guardian)
Name:

Name:

Relationship:

Relationship:

Phone:

Phone:

B. MEDICAL INFORMATION:
Family Doctor:

Phone:

Valid BC Medical Number:(if you do not have a valid BC Medical Number, please consent below)

I consent to my child’s participation in City of Richmond programs without medical insurance and understandany medical bills that arise from my child’s participation will be at my expense. Select one:  Yes NoIn the event that my child requires medical attention, I consent to my child being transported to the nearest
emergency centre, including by ambulance if necessary, and accept that I am responsible for any costs of such
ambulance service. Select one:  Yes
 No
Does your child require extra support in the program? Select one:  Yes

 No

If yes, please describe:
Does your child have any allergies (food, medication, environment)? Select one:  Yes

 No

If yes, please identify:
If allergy medication is required, you must complete ‘Allergy Emergency Action Plan” form.
Does the participant require medication(s) that need to be administered during the program?
Select one:  Yes

 NoIf yes, you must complete the "Permission to Administer Medication" form.
**Please Note: The responsibility for taking proper doses of medication cannot be assumed by staff and remains
the sole responsibility of the participant.

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City of RichmondInformed Consent and Permission Form

B. MEDICAL INFORMATION: (continued)
Are your child’s immunizations up to date? Select one:  Yes

 No

Date of most recent tetanus shot:Does the participant have any allergies or sensitivity to sunscreen? Select one:  Yes

 No

Do you consent for your child to apply sunscreen (provided by home or program)? Select one:  Yes

 NoI acknowledge that it is my responsibility to advise the City of any medical or other conditions that may affect mychild’s participation in the program(s). Select one:  Yes
 NoINITIAL HERE

I/we have accurately completed the medical information and will update staff of anychanges.

C. PARENT/GUARDIAN CONSENT:Your child will be involved in a number of activities as part of this program. These activities may include, but are
not limited to, walking, running, swimming and other sports. While all programs are supervised by trained staff
who instruct participants in safety, your child may still get injured, or your child's property may be damaged, as aresult of participating in the program.
Knowing and understanding the program, activities and risks, you freely agree to allow the participation of yourchild in the program. Select one:  Yes
 No

D. PICK UP AUTHORIZATION: (this section is only applicable for Children 0–12 years of age)
The following individuals are authorized to pick up my child at the end of this class. My child will only be released
to the individuals listed below. Identification may be required.
Name:

Name:

Relationship:

Relationship:

Phone:

Phone:

E. PHOTO RELEASE:
Phone:
Permission is hereby granted for the City of Richmond and/or its Community Partners to take and use
photographs of the above-mentioned child for promotions and records. Select one:  Yes
 No

F. AUTHORIZED RELEASE: (children walking home are recommended to be minimum Grade 2 and up)
My child is permitted to leave unaccompanied at the end of their program. Select one:  Yes

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City of RichmondInformed Consent and Permission Form

G. RELATED INFORMATION:
Does your child understand and/or speak English? Select one:  Yes

 No

If no, what other language(s) does your child speak?
Please indicate what swim level has been completed by your child.
Is there any other information that will helpful for our staff to ensure that your child have a successful program
experience?

H. SUBMITTING INFORMED CONSENT AND PERMISSION FORMS:
IMPORTANT: Please email your child’s Informed Consent and Permission Form along with a recent photographof your child to the facility where your camp is taking place. Please send the Wednesday prior to the start of yourchild’s camp in order to allow our team time review your submitted information. Our team will send you an email
confirmation upon opening of your email.
Alternatively, please bring this completed Informed Consent and Permission Form and a recent photograph ofyour child to the first day of camp. Thank you in advance for arriving early so that our team is able to review
your information. The completed package must be received before your child can participate in theprogram or camp.
Our facility email addresses are:

Arenas (Minoru Arena and Richmond Ice Centre): arenas@richmond.caArts Centre: artscentre@richmond.ca

Cambie Community Centre: cambie@richmond.ca

City Centre Community Centre: citycentre@richmond.caHamilton Community Centre: hamilton@richmond.ca

Nature Park: nature@richmond.ca

Nature School: natureschool@richmond.caRichmond Museum: museumed@richmond.caSea Island Community Centre: seaisland@richmond.ca

South Arm Community Centre: southarm@richmond.ca

Steveston Community Centre: stevestoncc@richmond.ca

Thompson Community Centre: thompson@richmond.caWest Richmond Community Centre: westrich@richmond.ca

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