The Québec Board of Black Educators

BANA Summer Institute 2023 program

Registration

Are you registering more than one child for the BANA PROGRAM?
If yes then you will need to register each child individually. After the first registration, you will need to enter some information in order to complete subsequent registrations

Are you registering more than one child for the BANA program?*

Yes

No

Who is this registration for?

Please enter the name of the first child registered.

Which grade level did you last complete?

Select the courses in order of priority that you require the most help*

Scale: 1. Need the most help with 3. Need the least amount of help

English

French

Math

Please select your preferred location

Marymount Academy

Disclaimer Kindly note that each center will operate as supported by the number of registrations.

BANA Fee Guide*

If paying the first week, you will be responsible for paying the following weeks.

BANA Weekly Fee Schedule

June 26 - June 30

July 3 - July 7

July 10 - July 14

July 17 - July 21

July 24 - July 28

July 31 - August 4

One Time Payment

BANA Weekly Fee Schedule

June 26 - June 30

July 3 - July 7

July 10 - July 14

July 17 - July 21

July 24 - July 28

July 31 - August 4

One Time Payment

Additional note:

BANA Weekly Fee Schedule

June 26 - June 30

July 3 - July 7

July 10 - July 14

July 17 - July 21

July 24 - July 28

July 31 - August 4

One Time Payment

Additional note:

Are you interested in daycare services?

Yes, I need mornings

Yes, I need evenings

Yes, I need both

Daycare Fees

One week

Two weeks

Three weeks

Four weeks

Five weeks

Six weeks

Daycare Fees

One week

Two weeks

Three weeks

Four weeks

Five weeks

Six weeks

Daycare Fees

One week

Two weeks

Three weeks

Four weeks

Five weeks

Six weeks

CONTACT INFORMATION

Student Information / Information étudiant

Which Organization referred you?*

Name*

First Name Last Name

Address*

#civic, street Apartment City Province Postal Code

Gender*

M

F

Date of Birth

Any health conditions or allergies we should be aware of? Please list below.

Cellular No

Email address*

CONTACT INFORMATION CONTINUED

Parent Information:

Parent*

Father

Mother

Guardian

Name*

First Name Last Name

Address same as student?

Yes

Address*

#civic, street Apartment City Province Postal Code

Home Phone*

Cellular No.

Email address*

Add Another Parent/Guardian?

Yes

Parent*

Father

Mother

Guardian

Name*

First Name Last Name

Same address as above?

Yes

Address

#civic, street / #civique, rue Apartment City Province Postal Code

(if different from the above one)

Home Phone*

Cellular No.

Email address*

MEDIA RELEASE CONSENT FORM

I hereby give the Quebec Board of Black Educators (QBBE) the right and permission to record my image or likeness while I participate in the Project/Event identified below. Furthermore, I hereby irrevocably give QBBE the right and permission to use my image or likeness so recorded.

QBBE’s right of use shall include the right to publish, adapt, exhibit, reproduce, edit, distribute and display my image or likeness in connection with any product or service for any purpose (including marketing, promotion advertising and trade) in all markets, media or technology now known or hereafter developed.

For certainty, and without limiting the above, QBBE’s right of use shall also allow it to publish my image or likeness on the internet, incorporate my image or likeness into promotional videos and share my image or likeness with media organizations for any purpose.

I shall not have any entitlement to compensation for QBBE’s recording and use and shall not make any claim against QBBE, its affiliates, agents, event partners, governors, officers and/or employees for damages that may arise from its recording or use including, without limitation, any claim that is based on an alleged misrepresentation, negligence, defamation, breach of privacy, right of publicity infringement or an infringement of any applicable privacy legislation.

By signing my name, I acknowledge that I have read, understand and agree with the contents contained within this Consent and Release.

If under 18 years of age, a signature of a parent or guardian is required. I acknowledge that I have read and understood this Consent and Release. I agree to its terms in connection with the photographic or electronic records of the likeness of my child:

Select the platforms you wish to give permission for use:

I grant QBBE permission to use my image or likeness on QBBE’s Website
I grant QBBE permission to use my image or likeness on the QBBE Newsletter & Official Reports
I grant QBBE permission to use my image or likeness on the QBBE Facebook page
I grant QBBE permission to use my image or likeness on the QBBE Instagram page

Project/Event: Fall 2021 Academic Support

Childs Name

First Last

Parent or Guardian's Name

First Last

Payment

Subtotal

$ 0.00 CAD

Processing Fee

Price: $ 0.00 CAD

Early Registration Discount

$ 0.00 CAD

Total

Credit Card

Cardholder Name

Card Details

Comments

This field is for validation purposes and should be left unchanged.