Formulaire d’inscription

Full name *

First

Last
Gender

Male Female
Date of birth *
Relationship to participant: *

Mother Father Legal guardian
Address *
Telephone *
Email Address
Choice of program *
Does your child have any medical issues or allergies? If yes, please explain *
Does your child have a special need? If yes, please explain. *
All reasonable steps will be taken to contact the parent(s), guardian(s) immediately in the eventemergency
I give my permission to take my child to the hospital or doctor in case of emergency
I give permission to allow my child to receive medical treatment either by way of first aid by an appropriately qualified person, either by a doctor at the hospital or wherever he goes. *
RISK ASSUMPTION:

I understand the risks inherent in physical activity. On behalf of the child in my care, I accept these risks and I agree to participate in the program listed above. I waive any legal proceedings on my part or on behalf of persons acting on my behalf against the organizers and their staff, for any damages or other inconvenience my child has while participating in the program or traveling to and from the program.
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Address of the field: Louis Riel Dome, 1659 Bearbrook Rd, Gloucester
Address:
Payment options: $250 per participant *

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