Masters Program Registration Form Paddler's InformationPaddler's Name* First Last Paddler's Gender*FemaleMalePaddler's Birthdate*Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Paddler's Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Paddler's Phone Number (###-###-####)*Paddler's Health Card Number*Paddler's email* Enter Email Confirm Email Paddler"s Membership Status*NewReturningProgram FeesPayment Method*Visa/Mastercard (2.5% processing fee)Cash--Cheque--Money OrderEmail TransferEmail Transfer Security AnswerEmail money transfers can be setup through your online banking. They are to be sent to email@example.com. All transfers require an answer to a security question, please enter the answer in the field above to the question for this transfer.Program Type: Masters Price: $ 200.00 CAD Total Registration Fees $ 0.00 CAD Emergency ContactEmergency Contact InformationEmergency Contact Name* First Last Primary Phone Number (###-###-####)*Alternate Phone Number (###-###-####)Paddler's Medical/Allergy InformationDoes the participant require medication?*YesNoPlease explain Does the participant have any allergies?*YesNoPlease explainUse of epi-pen required?YesNoIs the allergy life threatening/Anaphylaxis?YesNo Other Conditions?WaiverI hereby authorize staff to secure such medical advice and services as may be deemed necessary for the health and safety of the participant. I agree all information provided in this application is accurate and that I, and any paddlers who are part of this program, will abide by the Sack-A-Wa Canoe Club rules. I further understand that program fees cannot be refunded after the 1st week of the program, unless supported by a doctors certificate. I acknowledge and accept that participation in the sport of canoe/kayak and related recreational activities involves inherent risks. By signing this registration form, the member (guardian) hereby agrees to indemnify and save harmless Sack-A-Wa Canoe Club, its board of directors, members, volunteers, and/or staff against any and all liabilities or damages incurred, or which may arise, through activities associated with membership in the Sack-A-Wa Canoe Club. Agree?*YesNoNameThis field is for validation purposes and should be left unchanged.