2022 Spring Break Registration Package

Participant Information
Medications, Allergies, or Special Diets
Does your child have any known allergies or sensitivities to foods?
If YES, please explain in detail below. If NO, please write NOT APPLICABLE:
Please list current medications and supplements.
Please enter a phone number in the format 123-456-7890
Contact Information
Please enter a phone number in the format 123-456-7890
Please enter a value in the format A1B 2C3
Guardian 1 Information
Please enter a phone number in the format 123-456-7890
Please enter a phone number in the format 123-456-7890
Guardian 2 Information
Please enter a phone number in the format 123-456-7890
Please enter a phone number in the format 123-456-7890
Emergency Contact's Information
Please enter someone different than above.
Please enter a phone number in the format 123-456-7890
if applicable; if no diagnosis(es), write "not applicable"

Declaration of Compliance - COVID-19

All participants entering the facility must comply with this declaration.

By signing this document, I agree to follow club staff directives, and engage with all club requirements in Club Aviva’s COVID-19 Safety Plan. Additionally, I hereby acknowledge and agree to respect the following information outlined in this document:

  1. Sickness
    • I will stay home if I am unwell, or if someone in my household is unwell, or is displaying the following symptoms:
      • Fever and chills
      • Cough
      • Shortness of breath
      • Sore throat and painful swallowing
      • Stuffy or runny nose
      • Loss of sense of smell
      • Headache
      • Fatigue
    • I confirm that I have not knowingly been in contact with a person that has a confirmed or suspected case of COVID-19.
    • I agree to complete a routine daily screening process prior to entering my club.
    • I confirm that I have not travelled outside of Canada in the last 14 days. Additionally, I confirm that I have not been knowingly exposed to someone who has travelled outside of Canada in the last 14 days.
    • I acknowledge there are inherent risks associated with participating in activities. By attending club activities, I understand and assume all risks associated with potential exposure of COVID-19.
  2. Personal Hygiene
    • I agree to follow all personal hygiene requirements set out by my club, including but not limited to: frequent hand-washing and sanitizing, coughing and sneezing into my sleeve, etc.
  3. Physical distancing
    • I agree to practice safe social interactions, by maintaining a minimum distance of two meters between myself and others.
  4. Environmental hygiene
    • I agree to adhere to all club cleaning requirements.
  5. Physical modifications
    • I understand that equipment may be moved in order to facilitate safe social interactions and physical distancing.

Additionally, I understand and agree that if I do not adhere to the requirements set out by my club, I may be asked to leave the club activity in order to protect the health and safety of all involved.

This Participant Declaration of Compliance will remain in effect until GBC determines it is no longer required, based on viaSport, PHO, and WorkSafeBC requirements.

Please check the box below to indicate you fully understanding the content, meaning, and impact of this release.

Photo & Video Release Waiver

On occasion, photos, and video/DVD recordings may be taken during the course of Empowering Steps Sessions, Intensives, Year End shows, events, etc. Please be aware that the participant’s photos and/or recordings may be used for future promotional purposes, training or research purposes.

Please check the box below to indicate you fully understanding the content, meaning, and impact of this release.

I grant permission to Club Aviva Recreation Ltd, the Symington Symbiotic Foundation, and/or the Delta Gymnastics Society (the Service Providers) and their agents or employees to use photographs and/or video/DVD and audio taken of my child. Furthermore, I authorize the use of images of my child for all program promotion, materials, and any other purposes in connection with the program deemed appropriate and necessary by the Service Providers. I agree to release, defend, and hold harmless the Service Providers and their agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on Web sites, from any claim, damages, or liability arising from or related to the use of the photographs/video.

Research Release

Empowering Steps is a research-based program. Please check the box below to consent to the use of statistics and data on your child for research purposes. For statistical analysis, we may request the help of statisticians or other researchers who will respect the same rules of privacy and confidentiality. All analyses will be conducted on anonymized datasets where it is impossible to recognize any participant. In the event any results are published, it will be done so in a way that does not identify you or your child unless permission to do so has been obtained. We may also share the data with other researchers so that they can check the accuracy of our conclusions but will only do so if we are confident that your confidentiality is protected.

I consent to the use of my child’s data and information for research purposes. Only Club Aviva and Symington Symbiotic Foundation staff will have access to any information that could identify my child. I give permission for UBC researchers to work on documents generated by Club Aviva and Symington Symbiotic Foundation staff during Empowering Steps programs. This data will be extracted and all personal information removed before conducting the statistical analysis.

Release Agreement

I agree to complete the Release of Liability, Waiver of Claims, Assumption of Risks and Indemnity Agreement provided here

Third Party Billing (Automatic Funding)

In order to set up automatic funding or third party billing from an organization, Club Aviva must receive a confirmation letter from the organization that outlines the dates and amounts that the funding is available for. The customer is responsible for setting up funding with the organization. Until the confirmation letter has been received, the customer may be responsible for making the monthly payments using the post-dated cheques method of payment. Once payment has been received from the funding organization, we can reimburse the customer for that amount and return the remaining post-dated cheques for the term.

No retroactive funding changes will accepted. Written notice and confirmation is required for any funder changes. You are responsible to ensure that your funding is accurate and up-to-date. If there is a lapse in funding, services rendered will be charged to the credit card on file. Once funding has been re-established, you may be eligible for a refund.

  1. Autism Funding Unit (AFU) at the Ministry of Children and Family Development (MCFD):
    Club Aviva invoices the AFU at the MCFD for all services based on our hourly rate. If you receive funding from the AFU, please obtain a MCFD Autism Funding “Request to Pay” form (CF0925) from the ES Office, as we have already correctly completed the information needed for the “Service Provider” section which includes all of our services. You will need to complete the rest of the form, send directly to the MCFD or we will forward to MCFD on your behalf. If you send the form directly, please provide the ES Office with a copy for our records, in order to commence services. Incorrect forms result in delays, so please email esadmin@clubaviva.ca if you have any questions.
  2. Other Funding Agencies:
    If you receive funding from a different agency other than the AFU (MCFD), a confirmation letter must be given to the ES Office prior to your child starting services.

Post-Dated Cheques/EFTs

For clients who do not receive third party funding, post -dated cheques or an EFT for the entire year from Sep 1-Jun 1, are due upon registration and need to be dated for the first of each month. Please make cheques payable to Club Aviva Recreation Ltd. Cheques/EFTs will be processed on the first of each month and detailed invoices will be emailed at the end of each month.

Cancellation policy

All confirmed Intensives and sessions are subject to a no cancellation policy and will be billed in full. However, if provided with ample notice and a valid reason for cancellation, Club Aviva will consider placing a credit on your account to be used towards a future program. As per Club Aviva’s COVID-19 Safety Plan, clients should not enter our premises if they are experiencing any symptoms of COVID-19. Each request will be considered independently and Club Aviva reserves the right to charge a partial fee to cover wages.

Assumption and acknowledgment of risks for minors

Re: use of premises and equipment of Club Aviva Recreation Ltd and Delta Gymnastics Society

To: the above clubs, operating as Delta Gymnastics Society and Club Aviva Recreation Ltd. (referred to in this document as the named clubs) and Gymnastics BC, and the directors, officers, employees, representatives, officials, landlord and agents of both organizations

I have read the guidelines and rules issued for the use of the named clubs’ premises and equipment, which I understand, and I agree to be bound by them. I further agree to acknowledge that:

  1. The rules and guidelines governing the use of the premises and equipment are solely for that purpose, that is, for the use of gymnastics activities, and it remains my sole responsibility to act and govern myself in such a manner as to be responsible for my own safety;
  2. I am aware of the risks inherent in participating in gymnastics activities and the use of gymnastics premises, facilities and equipment and I assume the risks and waive notice of all conditions, dangers or otherwise relating to or arising out of such use.
I/We agree to uphold this contract between myself/ourselves, my/our child and Club Aviva Recreation Ltd. And abide by the terms set out therein, including but not limited to, the Cancellation Policy, Program Withdrawal Policy, Program Policies and Procedures, and the Assumption and Acknowledgment of Risks for Minors.
Please print the name(s) of parent(s) and/or guardian(s) that are signing.

Intensive Time Request

March 14-18
For each day, please indicate your first preference in the top row and second preference (if applicable) in the second row.
March 21-25
For each day, please indicate your first preference in the top row and second preference (if applicable) in the second row.
Please indicate if you prefer one specific day or have other information to add.

Session Time Request

To request a one-on-one therapy session please contact the Empowering Steps office

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