New ILRCC Member

Participants Name*

First Last

Main Contact Email*

Address*

Street Address Address Line 2 City 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 Phone

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?

Choose Program

Payments

12 week program Registration

Price: $ 110.00 CAD

$110.00/program *Excludes Arts & Crafts, Cooking, Focus 4 Health, Desserts & Monday Arts and Drawing

Arts & Crafts Registration

Price: $ 135.00 CAD

$135.00/program (includes supplies)

Focus 4 Health Registration

Price: $ 90.00 CAD

$90.00/program

Cooking & Desserts

Price: $ 75.00 CAD

$75/program

Miscellaneous

Price: $ 1.00 CAD

For Miscellaneous charges

Total

$ 0.00 CAD

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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