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Registration

Annual Family Conference
Youth Forum Registration Form

***** Note: Please fill out a separate form for each youth who would like to register for the forum – all information must be filled out. Please be advised that although this is a participatory workshop, support can be made available. Thank you. *****

Saturday, March 15, 2008

Fantasyland Hotel
17700-87 Avenue
Edmonton, AB T5T 4V4
Phone: 1.888.737.3738

Families – the Heart of Community

Click here to download the Conference brochure, including the Youth Forum Registration Form.


	Information about you:
First Name:
Last Name:
Address 1:
Address 2:
City:
Province/State:
Postal/Zip Code:
Home Phone:
Cell Phone:
Work Phone:
Email:
Age:
Do you have a disability?	Yes No
If yes, please explain:

Do you require individual support?	Yes No
Can you bring your own support person?	Yes No
Please explain the type of support you require:

Do you have any medical concerns we should know about?:	Yes No
If yes, please describe. (Please note our staff are not able to administer any medication.)

Do you have seizures?	Yes No
Do you have allergies?	Yes No
Please describe any precautions that must be taken for seizures or allergies:

Is there any additional information we need to know in order to assist you to participate in the forum? Please remember that we want all participants to be fully engaged in the forum. Thank you!

To be Completed by Parent or Guardian if the Youth is Under the Age of 18:
Youth's Health Care Number:
Information about Parent or Guardian:
First Name:
Last Name:
Home Phone:
Cell Phone:
Pager:
Email:

Created by ploneAdmin
Last modified 2008-01-11 20:08