Welcome to ILRCC – Wednesday Pizza Night "*" indicates required fields Has the participant attended any of our programs before?*Select an optionYesNoParticipants Legal Name* First Middle Last Participant's Preferred Name (If Applicable) First Middle Last Participant's Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Participant's PronounsSelect an optionShe/HerHe/HimThey/ThemPrefer Not to SayOther (Please Specify)Other Pronouns*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 Middle Last Emergency Contact Email* Emergency Contact Phone*What is the participant's preferred program location?*Select an optionBoston Pizza at Memorial Drive (2836 Memorial Dr, Calgary, AB T2A 6L6)Boston Pizza at Southport (10456 Southport Rd SW, Calgary, AB T2W 3M5)Will participant use Calgary Transit Access to come to programs?*Select an optionYesNoSometimesAccess #*Will the participant need to be handed over?*Select an optionYesNoNumber of support person(s) that the participant requires?*0123+Primary Support Person Name* First Middle Last Primary Support Person Phone*Does the participant require constant supervision by the support person(s)?*Select an optionYesNoMedical 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?*Photo/ Media ConsentILRCC may occasionally take photos and/or videos during programs for promotional purposes. Please indicate whether the participant consents to their image and/or video being used in any website publication or multimedia production (Instagram, Facebook etc.). Consent may be withdrawn at any time by contacting ILRCC.Do you consent to ILRCC taking and using photos/videos of the participant?* Yes, I do consent. No, I do NOT consent. Who is signing this consent?* Participant Parent/ Guardian Trustee/ Support Person / Organization staff Name of Parent/ Guardian/ Trustee/ Staff* First Middle Last Electronic Signature*Use your mouse or finger to sign in the box.Refer a Friend and Get Rewarded!If you were referred to ILRCC by someone who attends our programs, the referrer will receive a $25 dollar gift card!Were you referred by someone who attends our programs?* Yes No Who referred you?* First Middle Last Referrer's Email Address* Referrer's Phone Number*PaymentsWednesday Pizza Night Registration Price: $110.00/program Total Payment Method* E-transfer Cash Cheque Credit Card Please send your e-transfer to ed@ilrcc.ab.caPlease mail or drop-off to our locationCredit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name CAPTCHA
