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First Name *

Last Name *

Date of Birth (YYYY *-MM-DD)

/ /

Gender

Home address and postal code

Guardian 1

Guardian 1 Phone Number - International Number

Guardian 2

Guardian 2 Phone Number

Guardian 3

Guardian 3 Phone Number

Guardian 4

Guardian 4 Phone Number

Emergency Contact

Emergency Contact Phone Number

Other people for pick up

Iron Women organizers may contact you via email with important program information and updates. In addition to the billing email address on file please let us know who else needs to receive these emails. Opt in to emails

In the event of an accident, I authorize Iron Women employees to provide my child with required first-aid. If required, I authorize transportation by ambulance to alternate healthcare. I authorize Iron Women to release the information provided in my child's health record.

Family Doctor

Family Doctor Phone Number

Yukon Territory Health Care Number

Does your child have any medical conditions that we should know about?

Does your child have any behavioral issues we should know about?

Does your child have any allergies or intolerances? If so, what are they?

Is there anything else you would like to tell us about your child?

Distance

Category *

Waivers

I have read and agree *
AY Waiver

Digital signature (type your name exactly as entered above "registrants name") *

Ironwomen - JR After School Program Winter 2024

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Distance

Waivers