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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?

All Access (select access type)*

1-month unlimited program access ($50.00)
3-months 1 program access ($100.00)
3 months 2 or more unlimited programs access ($150.00)

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$ 0.00 CAD

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