Registration Form

To see if this program will meet your needs and to help us with planning,
please complete and return this form to us in any of the following ways:

Mail to: IWK Paediatric Rehabilitation Program

C/O Kim Clarke Rm K2216
5850/ 5980 University Ave
PO Box 9700, Halifax NS B3K 6R8

Email to: kim.clarke@iwk.nshealth.ca

Fax to: 902-470-7465 att: Kim Clarke

Call to complete by phone: 902-470-7039

Program:
Encouraging Advocacy and Sexual Education- E.A.S.E For Girls
Encouraging Advocacy and Sexual Education - E.A.S.E For Parents
Junket
Paralympic Possibilities March Break Camp
Preschool Leisure and You (P.L.A.Y)
Sibling Workshop

Participant’s Name Date of Birth and/or IWK #

Address Postal Code

(902) (902) (902)

Home Phone Mom/Dad Work Cell/ Emergency #

School Grade

Participant’s Email

Diagnosis (or Diagnosis of Sibling):

Parent(s) Names

Parent(s) Email

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Please indicate any areas of special needs and make comments as required:

Special Need Comments:

□ Eating:
□ Speaking:
□ Remembering:
□ Allergies:
□ Reading:
□ Socializing:
□ Organizing Ideas:
□ Listening:
□ Medical Needs:

Please tell us about any adaptive supports and/or technical aids which help in any of these
areas:

Physical Abilities:
Arms/hands: No problems □
Some difficulty (please identify challenges):

Unable to write or use hands well □

Walking: No problems □
Walking Aids
(please identify amount of support/supervision required):

Manual Chair □
Power Chair □

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What do you hope to get out of this program for your child/ your family? Do you have any
particular goals you would like addressed?

Yes, please add my email address to your family email distribution list to receive
information and updates on upcoming programs as well as other useful
information.

Thank You!

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