EmailMe Form - CANADA’S WONDERLAND REGISTRATION APPLICATION

Name *

First Last

Age:

Date of Birth *

MM / DD / YYYY

Gender *

Male

Female

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Email *

Phone

### - ### - ####

Name of High School/College/University:

Grade/year:

Parent/Guardian

Name

First Last

Relation with Attendee

Home Phone

### - ### - ####

Work Phone

### - ### - ####

Cell Phone

### - ### - ####

City

Province

Email Address

Emergency Contact Information

Name

First Last

Relation with Attendee:

Home Phone:

### - ### - ####

Cell Phone:

### - ### - ####

Email Address:

Medical Release Information:

The purpose of the below listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment

Name of Physician:

Physician's Phone Number:

Health Card Number:

Please list any allergies/medical problems, including requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

Medical Diagnosis:

Medication:

Dosage:

Frequency of Dosage:

PAYMENT INFORMATION

We cannot accept verbal registration. This application must be completed fully and signed by a parent or guardian for each applicant (if under 18 years old). APPLICATIONS WILL NOT BE CONSIDERED UNLESS ACCOMPANIED WITH THE FEE OF $50 IN THE FORM OF A CHEQUE OR CASH. ALL FEES ARE PAYABLE IN CANADIAN FUNDS.

Registration Form, Parental Consent Form and cheque/cash to:
MAC Youth Centre 362-366 Oxford Street, London Ontario
Thursday to Sunday from 6-10pm or drop off in mailbox located outside the MAC Center or hand to brother Omar Sallam inside the MAC centre.

Please make all cheques payable to “MUSLIM ASSOCIATION OF CANADA” – in the memo please indicate “Canada’s wonderland Trip”