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?

Programs/Activities*

Programs Registration*

Price: $ 70.00 CAD

$70.00/Per program - *Excluding Cooking*

Learn to Cook Registration

Price: $ 60.00 CAD

Cooking is $60.00

Misc Sales Item

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

Total

$ 0.00 CAD

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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