Your Reservation

Would you like to continue completing the registration forms for each participant or make payment?

If you choose to make payment, you will be prompted to enter an email address for each participant so that they may complete their own registration form under this booking.

Completing this registration

This registration form has been broken down into several sections. All participants are required to complete an electronic registration.

To complete this form, you will need the following:

Your BC Medical Services Plan (MSP) number (if applicable)
The names and contact numbers of three (3) people who can be contacted in an emergency
Your doctors name, address and phone number

At the end of the registration process you will be directed to an online payment screen where your deposit or full payment can be paid using a credit card. If you need to locate information, please leave this page open on your computer without refreshing the page. Once the page is refreshed you will have to restart your application.

2018-06-16	RCABC Lakewater Level 1 Certificate	Ref: DAY77	$185.00
Total Cost: $185.00

Personal Information

Please fill in this form with as much information as possible when registering. Do not use the back button in your browser, but use the Green buttons at the bottom of each section.

First Name

Last Name

Mailing Address

City

Postal Code

Telephone

Email Address

Date of Birth:

Health and Diet

Please list any allergies or medication that the youth has to take and any physical condition that may affect participation in events and activities.

Food and Dietary Information

Please indicate if the applicant has any special dietary needs

Vegan

Vegetarian

Dairy Free

Gluten

None

Please select any Food Allergies from the boxes below

Peanut	Milk	Egg	Wheat	Soy
Fish	Shellfish	Other

If you have checked any of the boxes above, please give details below.

Emergency & Medical Information

In the unlikely event that we need to contact someone on your behalf, please list three contacts that we can call and indicate if they have your permission to pick up the participant if necessary.

Contact #1 Name	Contact #1 Phone	Contact #1 Cell	Participant can be released to this person?
Contact #2 Name	Contact #2 Phone	Contact #2 Cell	Participant can be released to this person?
Contact #3 Name	Contact #3 Phone	Contact #3 Cell	Participant can be released to this person?

Please give the participants" medical insurance information.

Provincial Medical Plan Number (MSP) (if applicable) Do you have private medical insurance? Provider:

Please give your family doctor information.

Physician"s Name Physician"s Phone
Physician"s Address

Medical History

The following information will help us to understand your needs. This information will be shared with medical professionals if necessary when administering treatment.

Does the participant have any of the allergies listed below?

Medicine	Insect Bites	Toxins	Food	Smoke
Plants	Animals	Bee Stings	Dairy	Other

If you have checked any of the boxes above, please provide mroe information in the box below

Has the participant had any of the following?

Appendicitis	Mumps	Chicken Pox	Measles	Kidney Disease
Rhumatic Fever	Scarlet Fever	Heart Condition	Other

If you have checked any of the boxes above, please provide more information in the box below

Medical History

Is the participant subject to any of the following conditions?

Asthma	Contact Lenses	Headaches	Fainting	Bleeding Disorder
HIV	Ear Problems	Diabetes	Hernia	Back Issues
Motion Sickness	Cramps	Convulsions	Sleepwalking	Nightmares
Bed Wetting	Other

If you have checked any of the boxes above, please provide more information in the box below

Date of most recent physical examination:

Date of last tetanus shot:

Fitness & Activities

The participant can swim 50 metres unassisted Yes
The participant is a non-swimmerYes
The participant can hike 10kmYes

Has it ever been necessary to restrict the participants activities for medical reasons? Yes

If Yes, please provide more information in the box below

Please be patient when you click Finish, it may take a minute or two to process!

Notify Participants

Complete the email addresses for each of the remaining participants and we"ll ask them to complete their registration form on your behalf. They will not be asked for payment.

Once you click on the button below, you will be redirected to make payment for your group adventure.

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Your Reservation

Your Reservation

Completing this registration

2018-06-16

RCABC Lakewater Level 1 Certificate

Personal Information

Health and Diet

Emergency & Medical Information

Medical History

Medical History

Fitness & Activities

Notify Participants

Team Building

Useful Information

Tours & Expeditions

Expedition Tours

Adventure Tours

Education Groups

Other Groups

Elk Bay Adventures

Mailing Address

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