Program and Membership 2022 Registration Form "*" indicates required fields HiddenPayment Received (Yes/No)/Format Personal InformationName* First Last Date of Birth* Month Day Year Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 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?Photo 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 I have read and agree to terms listed in the Waiver for participants under 18 years old Name of Participant (over 18 years old)* Name of Parents/ Legal Guardians (under 18 years old)* Applicant's Signature (Over 18)Date Signed* Month Day Year General Membership Fee* Register as a new or returning member with expired status + $5.00 I am a registered member and have maintained status within 1 year +$0.00 What program are you joining (select all that apply)?* Aqua-Abilities (Charlottetown) Aqua-Abilities (Summerside) Adult Fitness Para-Cycling Parafit PEI Mustangs Wheelchair Basketball Junior Wheelchair Basketball Total Payment Method* Credit/Debit Card Cash/Cheque Email Money Transfer Credit/Debit Card*Card Details Cardholder Name Please EMT to: [email protected]Please Make Cash/Cheque Payble To: ParaSport and Recreation PEI 40 Enman Crescent, Room 123 Charlottetown, PEI C1E 1E6 Δ
