Community Programming Registration

AMPED2PLAY Course Registration Profile

Please complete the following registration profile prior to attending your AMPED2PLAY Programming. Thank you!

TIP!: When selecting your date of birth on a mobile device, first click on the empty date box, and a calendar will appear with the month and year between two arrows at the top. Click on that header repeatedly until you see the menu where you can select your birth year. Once you have selected the appropriate decade, it will guide you to select the year, month, and the date that you were born. You do not have to continuously click on the arrows to reach your birthdate.

*If you are attending our PLAY6S Community Programming at Oriole Park Elementary School throughout April and May, payment of $90 per participant and $40 per sibling/peer will be collected on the first day of programming. Payment will be accepted via e-transfer, credit card or cheque.

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* 1. Course Location:

City

Province/State

Country

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* 2. Date of Course

(MM/DD/YYYY)

Date

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* 3. Select the AMPED2PLAY Community Program You are Registering for:

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* 4. Personal Information: The information provided in this section is only for use of tracking individuals for AMPED2PLAY Community Programs and related liability purposes and will in no way be distributed for any other purpose. If you are in agreement to provide your information, please check the appropriate box below.

I agree to provide my personal information for AMPED2PLAY training and certification tracking

I agree to provide my child's personal information for AMPED2PLAY training and certification tracking

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* 5. Registrant's Contact Information:

Name *

Address

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number

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* 6. Please Provide Registrant's Birthdate:

(MM/DD/YYYY)

Date

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* 7. Please Provide Registrant's Gender:

Female

Male

Non-Binary

Two-Spirit

Prefer Not To Say

Other (please specify)

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* 8. Participant's Information:

Name *

Address

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number

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* 9. Please Provide Participant's Birthdate:

(MM/DD/YYYY)

Date

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* 10. Please Provide Participant's Gender:

Female

Male

Non-Binary

Two-Spirit

Prefer Not To Say

Other (please specify)

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* 11. Emergency Contact:

Name

Relation

Primary Phone

Secondary Phone

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* 12. What Drew You to This AMPED2PLAY Program?

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* 13. Who is Joining the Registered Participant in Play?

Parents

Aides/Caregiver

Siblings

Friends

Teachers

Other (please specify)

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* 14. Do you or any members of your family have any special considerations our staff team should be made aware of in order to ensure an optimal PLAY6S experience?

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* 15. Are there other Community or Sport programs that the registrant is presently active in?

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* 16. Additional Comments?

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* 17. What is Your Preferred Language?

English

French

Other (please specify)

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* 18. Photo Release:

I, as a participant in this AMPED2PLAY course, give full permission to use any photographs or movies taken during the course.

I, as a participant in this AMPED2PLAY course, do NOT give permission to use any photographs or movies taken during the course.

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* 19. Please check the box below to acknowledge that you understand you are required to stay in the gym with your registered child. For liability purposes and safety, a parent or aide is required to stay for the duration of the program in the gym.

Agree