Recreation: New User : A Healthy Lifestyle (Recreation) : Programs : Favarh

Recreation: New User

For tutorials on how to register as a new user, click here.

User Information

Username

Password

Passwords should contain at least 1 letter and 1 number; can contain the @ # $ ^ * ! - characters; be at least 6 characters in length; not be the word PASSWORD; and not be the same as your username.

Confirm Password

Recreation Participant Information

First Name

Last Name

Participant Address (Line 1)

Participant Address (Line 2)

City

State

Zip Code

Phone

Participant E-mail Address (if applicable)

Gender

Age

Ethnicity

Seizure Disorder

Known Allergies

Please fill in all known allergies or write "None"

Medications - If Any

Include: Name of Medication(s), Dosage and Frequency

Dietary Restrictions

Please fill in all known dietary restrictions or write "None"

Primary Contact Information

First Name

Last Name

Relationship to Participant

Primary Contact Address (Line 1)

Primary Contact Address (Line 2)

Primary Contact Additional Phone

Emergency Contact Name

Emergency Contact Phone

Additional Emergency Contact Name

Additional Emergency Contact Phone