registration testing | Come As You Are

Your Name *

First

Last

Address *

City and Province *

Postal Code *

Your Phone Number *

Your Email *

Emergency Contact Name *

First

Last

Address *

Phone Number *

Emergency Contact Relationship to You *

Do you have any health conditions we should be aware of?

If yes, please list them.

Do you have any special dietary needs?

If yes, please list them.

Are you on any medications we should know about?

(We have a locked safe to store your medications privately should you request this option.)

If yes, please list them.

Are you able to participate in recreation including walks?

If no, please explain.

So we can ensure you get maximum benefit from this weekend, please tell us a little bit about youself. *

Why did you choose to treat yourself to this weekend? *

What are your expectations and/or fears for the weekend? *