Gateway Holistic
9218 Ellerslie RD SW, Ste 195,
Edmonton, AB, T6X0K6
info@gateway-holistic.com
www.gateway-holistic.com
(780) 239 6674
PD Day Registration Form
Lets Get The Details:
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Would you like to be signed up for PD Day Services for every scheduled EPSB PD Day?
*
Yes!
No, just this one for now.
Are you already a client of Gateway Holistic?
*
Yes
No
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
-
Month
-
Day
Year
Date
Current Age
Primary language spoken at home:
*
What is your clinical diagnosis?
*
What level of care do you require?
*
Level I
Level II
Level III
Impairment Level:
*
Alert
Alert (Occasional Confusion)
Mild Impairment (Some Confusion)
Moderate Impairment (Confused, memory trouble)
Severe Impairment (Affects All Aspects of Life)
Risk Factors - Please select all that apply.
*
Combative
Disruptive
Withdrawn
Self-harm Tendencies
Wanderer
Repetitive
Abusive (mentally/physically)
None
Please list any allergies:
*
Please describe any dietary requirements:
*
Please list any sensitivities:
*
e.g., noise, crowds, etc
Do you require wheelchair accessibility?
*
Yes
No
Please provide a schedule and list of any daily medications that will need to be administered:
*
Please list 3-5 of your favorite activities to help us get to know you better!
*
Emergency Contact
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship to child:
*
FSCD Caseworker
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
File Upload
*
Browse Files
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Is there anything else you would like to tell us?
PHOTO DISCLAIMER: By proceeding, you hereby grant Gateway Holistic Care Group permission to take and use photographs of your child for marketing and promotional purposes. You acknowledge and agree that these images may be used by the company in various publications, press releases, promotional activities, or on the company's website. By providing your consent, you release and discharge Gateway Holistic Care Group from any and all claims arising out of the use of these photographs. Have you read and understand these terms?
*
Yes
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