Welcome to ILRCC – Wednesday Pizza Night "*" indicates required fields Are you a member?*YesNoParticipants Name* First Last Main Contact Email* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Emergency Contact Name* First Last Emergency Contact Email* Emergency Contact Phone*Will participant use Access Calgary to come to programs?Access #If participant is arriving by Access Calgary, do they need to be handed over?Primary Support Person Name First Last Primary Support Person PhoneMedical 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?Preferred Location*Boston Pizza at Memorial Drive (2836 Memorial Dr, Calgary, AB T2A 6L6)Boston Pizza at Chinook (6455 Macleod Trl SW #232, Calgary, AB T2H 0K8)PaymentsWednesday Pizza Night Registration Price: $110.00/program Total Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name CAPTCHA
