Program and Membership Registration "*" indicates required fields HiddenPayment status Paid Missing $10 Refunded Membership Type*Effective immediately, ParaSport and Recreation PEI membership fee is $10. Annual membership runs from July 1, 2023 to June 30, 2024. New members or returning members with expired status Registered members with valid status renewed after July 1, 2023 Personal InformationName of Participants* First Last Date of Birth* Month Day Year Name of Parents/Legal Guardians (if participants are under 18) First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Email* Emergency Contact InformationName* First Last Relationship* Phone*Medical InformationDoctor's Name* First Last Doctor's Phone Number*Provincial Health Card Number* Do you have a physical disability?* Yes No If yes, please identify. Do you have a visual disability?* Yes No If yes, please identify. Do you have an intellectual disability?* Yes No If yes, please identify. Do you have any existing medical conditions (e.g. asthma, heart conditions, high BP)?* Yes No If yes, please identify. Do you have any allergies?* Yes No If yes, please identify. Is there any important/relevant information about your condition that you would like to share with us?Waiver and ConsentPhoto Release Consent*ParaSport and Recreation PEI may take photographs or videos of participant to publish on ParaSport and Recreation PEI’s website, newsletters, newspapers, or social media. By ACCEPTING these terms and conditions in its entirety, you give permission for you/your child to be included in these photographs/videos and agree that you have read and understand the policy. I authorize ParaSport and Recreation PEI to take and use any photos and/or videos taken of me/my child during their programs or events. Yes, I allow my picture to be taken No, I do not allow my picture to be taken Terms and Conditions* I have read and agree to terms listed in the Waiver for participants over 18 years old Terms and Conditions* I have read and agree to terms listed in the Waiver for participants under 18 years old Print name* SignatureDate Signed* Month Day Year Programs and FeesWhat program are you joining (select all that apply)?*Please DO NOT sign up if program REGISTRATION is CLOSED PEI Ice Breaker Para Ice Hockey Season Junior Wheelchair Basketball Adult Fitness 1 session/week Adult Fitness 2 sessions/week Curling REGISTRATION CLOSED - Advanced Aqua-Abilities (Charlottetown) REGISTRATION CLOSE - Para-Cycling REGISTRATION CLOSE - Aqua-Abilities (Charlottetown) REGISTRATION CLOSED-Charlottetown Sunday Boccia REGISTRATION CLOSED-Aqua-Abilities (Summerside) REGISTRATION CLOSED-Parafit REGISTRATION CLOSED-Senior Wheelchair Basketball REGISTRATION CLOSED-PEI Ice Breaker + Sled Damage Deposit HiddenWhat is your jersey's size?*Please click here to view youth jersey sizing chart. XS S M L XL HiddenWhat is the last name you want printed on the jersey?* HiddenWhat is your preferred number on the jersey (01-30)?*Please enter a number from 1 to 30.Total Payment Method* Credit/Debit Card Cash/Cheque Email Money Transfer Credit/Debit Card*Card Details Cardholder Name Please EMT to: info@parasportpei.caPlease Make Cash/Cheque Payble To: ParaSport and Recreation PEI 40 Enman Crescent, Room 123 Charlottetown, PEI C1E 1E6Newsletter Subscription Subscribe to ParaSport Newsletter By clicking this box, I agree to receive emails about programs and events from ParaSport and Recreation PEI. Subscribe to ParaSport's member exclusive news By clicking this box, I agree to receive emails about programs and events exclusive to registered members from ParaSport and Recreation PEI. Δ
