L&A Youth Hub Program Registration

1. Registration and Consent

Welcome and thank you for registering!

If you have any questions about this registration form please contact:

Shannon Ruddy
Youth Hub Coordinator
Napanee Area Community Health Centre, part of Kingston Community Health Centres (KCHC)
Email: shannonr@kchc.ca  |  Mobile: 613-539-9933

Today's Date:


1. Please tell us what Lennox & Addington Youth Hub program(s) you are registering for?


2. What is the location of the Youth Hub Program?


3. Name and Address


4. Please enter or select your: *


5. Gender (self-identified)


6. Preferred language:


7. Indicate if you identify as:


8. Contact Information


9. EMERGENCY Contact Information *


10. How did you hear about the L&A Youth Hub programs?


11. Do you have any allergies/intolerances/sensitivities?


12. Describe any help you may need to make programming more accessible (communication, mobility, other):


13. Other questions or comments:


Consent to Participate

Please select the appropriate statement below. *

Protecting Your Privacy

Kingston Community Health Centres ("KCHC") is committed to protecting your privacy  and  to keeping your personal health information safe. The steps we take to protect your information are described in our Privacy Statement and Privacy Policy. Please ask to see these if you would like to know more about our privacy practices.

KCHC is a single, multi-site agency that provides medical and non-clinical services to help people.

KCHC will collect and use your personal health information in order to provide health care services to you and for other reasons that are explained in our Privacy Statement. We will only collect personal health information that is necessary to provide services to our clients. All KCHC staff who provide services to patients and clients will use and see clients' personal health information.

Only authorized staff members are entitled to access clients' personal health information, and they can only do so when they require this information in order to provide services.

We will not usually collect, use or share your personal health information without your permission. If you give us permission to give out your information, you can change your mind at any time. There are exceptions to this which are explained in our Privacy Statement and Privacy Policy.

You have the right to know how we may use your personal health information and how you can get access to do it.  If the information  we have is inaccurate  or incomplete,  you can   ask us to correct it. You can ask us not to give your information out to other health care providers, and we will not do so unless the law allows or requires us to. Please ask any KCHC staff member to help you do this.

If your information is lost or stolen or improperly accessed, we will tell you.

If you have a concern, please discuss it with our Privacy Officer. They can be reached at 613-539-9701. If you still have concerns, you can contact the Information and Privacy Commissioner of Ontario. Our Privacy Statement explains how to do this. *


Working Together at KCHC - Rights and Responsibilities

Our part:
  • Your information will be confidential.
  • We will treat you with respect.
  • We will tell you about all available services.
  • We will give you clear and up-to-date information.
  • We will tell you when you are receiving services of a student and that you have a right to refuse these services.
  • You can refuse treatment and we will explain what will happen if you do.
  • We will listen to your feedback.
Your part:
  • Show respect to everyone, both staff and other clients, at KCHC.
  • Tell us when you do not understand  any information  we give you.
  • Respect KCHC policies.
  • We are a scent-free environment, please do not wear scents when coming to the centre.
  • Tell us when you change your address or phone number.
  • Arrive on time for appointments.
  • Accept responsibility for the decisions you make about your care.
  • To cancel an appointment, we require 24 hours' notice. If you miss 3 appointments in a row without telling us, you could lose access to services.


Please enter or select: *