Registration Form
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Emergency Contact Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
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Next
Medical Information
Provincial Health Card Number
*
Doctors Name
*
Doctor's Phone Number
-
Area Code
Phone Number
Do you have a physical disability?
*
Yes
No
If yes, please identify
Do you have a visual disability?
*
Yes
No
If yes, please identify
Do you have an intellectual disability?
*
Yes
No
If yes, please identify
Do you have any existing medical conditions (e.g. asthma, heart conditions, high BP)?
*
Yes
No
If yes, please identify
Are you currently taking any medications?
*
Yes
No
If yes, please identify
Do you have any allergies?
*
Yes
No
If yes, please identify
Is there any important/relevant information about your condition that you would like to share with us?
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Program
What program are you joining (select all that apply)?
*
PEI Ice Breakers Sledge Hockey
Wheelchair Basketball
Aqua-Abilities
Para-Fit
CanSkate Sledge
Para-Cycling
Target Shooting
Other
Photo Release
ParaSport and Recreation PEI may take photographs or videos of participant to publish on ParaSport and Recreation PEI’s website, newsletters, newspapers, or social media. By ACCEPTING these terms and conditions in its entirety, you give permission for you/your child to be included in these photographs/videos and agree that you have read and understand the policy. I authorize ParaSport and Recreation PEI to take and use any photos and/or videos taken of me/my child during their programs or events.
*
Yes, I allow my picture to be taken
No, I do not allow my picture to be taken
Date
-
Month
-
Day
Year
Date
Signature
Parent or Guardian Signature (U18 years)
Submit
Should be Empty: