Winter Program Registration
Please complete the following to ensure we have the most up to date information.
Participant Name *
Your answer
Age *
Your answer
Date of Birth *
Your answer
Gender *
Home Phone Number *
Your answer
Cell Phone Number
Your answer
E-mail *
Your answer
Highschool *
Your answer
Grade *
Your answer
Parent #1 Name *
Your answer
Parent #1 E-mail *
Your answer
Parent #1 Phone Number *
Your answer
Parent #2 Name
Your answer
Parent #2 E-mail
Your answer
Parent #2 Phone Number
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Health Card Number *
Your answer
Is there any medical information (ie. allergies, chronic diseases, pre-existing conditions, etc.) or other information that we should be aware of in order to provide safe and effective programming to your child/ward?
Your answer
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