Contact Information
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Billing First Name:
Billing Last Name:
Physical Address:
PO Box:
Country:
Prov/State:
City:
Postal/Zip Code:
Phone 1:
Phone 2:
Email:
Client #:
Account Information
Username:
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Password:
Re-Type Password:
Password Strength
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Uppercase and lowercase characters
Numbers
Symbols
Eight or more characters
Extra Information
Sex At Birth:
Male
Female
X
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Birthdate:
Emerg. Contact:
Emerg. #:
Permission To Take Photo(s) Granted?:
I understand that I/my child will be participating in activities that may have a high risk and I agree to release and hold harmless the District of Port Hardy, its employees, officers, agents, affiliated community association, and volunteers, from any claims for injury, loss of life, or damage that I/my child may sustain while participating, including claims of negligence. I acknowledge that while the District of Port Hardy is taking measures to lower the risk of the spread of the Coronavirus, COVID-19, it does not guarantee its ability to do so:
Medical Information
Do you have any of the following conditions or requirements?:
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