Registration Page

Name*

First Last

Email*

Address*

Street Address Address Line 2 City Province Postal Code

Emergency Contact Name*

First Last

Emergency Contact Phone

Access #

Primary Care Giver Email

Primary Support Person Email

Medical concerns/conditions ((including dietary and other restrictions such as caffeine, sugar, etc.)

What to do to do if one of the concerns is encountered.

Anything that would be helpful to staff while attending community and social events with you? (behavioural challenges, noise or light sensitivities, fears such as heights or loud bangs, stairs or escalators, etc., anxiety or other social phobias)?

Do you use a walker, wheel chair or other assistive technology that we should know about?

3-Months First Program*

Price:

Extra Programs ($50 each)

Price: $ 50.00 CAD

Kids Chat Line ($15.00 per month)

Price: $ 15.00 CAD

ILRCC will reach out to you after registration to determine which programs you wish to partake in.

CAPTCHA

Total

$ 0.00 CAD

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Make a Difference

Useful Links

Blog/News

Follow Us On

My Account