weekly email form (airfryer)

Please fill out the form below to reserve a spot for this Saturday.

This program requires monthly invoicing, However it is passport funding & SSAH friendly.
Name (Guardian/CareProvider)*

First NameLast Name
Name (Who are you reserving for?)*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
2nd Emergency Contact*
Please enter a valid phone number.Format: (000) 000-0000.
See Below For Time Slots Available, Alergies & Eligibility
FRIDAYS

10 - 2pm
Select an option below)*

One time Drop in - $85 per personfriday Membership – $340/month (Regular $500/month – limited-time rate, ends July 1)Interested in another day (waitlist applies)
choose your start date (fridays only)*

MonthDayYear
Date
FRIDAYS

10am - 2pm
Select an option below

Friday Drop in - $105/DayFriday Membership - $340/month (Regular $500/month – limited-time rate, ends July 1)
choose your start date (Fridays only)

MonthDayYear
Date
Any Allergies ?*

YesNo
Describe Allergies*
Special Note on Allergies and Concerns*
When using shared kitchen appliances like air fryers, do you have any specific cultural, religious, or personal requirements regarding food contact? (For example: Not using the same basket for meat and vegetarian items, specific cleaning rituals, or avoiding certain food groups entirely*
IMPORTANT - NOTICE

Eligible Participants

Participants should generally meet the following profile as a minimum requirement:

Gross Motor Skills: 6/10
Communication Skills: 5/10
Independence: 5/10
Receptivity to Instruction: 7/10
Challenging Behaviours Requiring Clinical Therapy: 0/10

This program is not designed for individuals who require active behavioural or clinical intervention.

If eligibility is unclear or you’re unsure whether this program is the right fit, please contact us directly at Reclifegma@gmail.com to discuss individual circumstances.
Do you consent to having us send & upload progressive videos on our instagram page @reclifegma and website reclifegma.ca

YESNO
Media Release signature
Address : 6033 Shawson Dr, Mississauga, ON L5T 1H8 , UNIT 22
What's next ?

We will call/email to confirm attendance; take Note of the upcoming Date/Time . Email us for any questions/concern : Reclifegma@gmail.com
Should be Empty:

Please fill out the form below to reserve a spot for this Saturday.

See Below For Time Slots Available, Alergies & Eligibility

FRIDAYS

FRIDAYS

Address : 6033 Shawson Dr, Mississauga, ON L5T 1H8 , UNIT 22

What's next ?