CP Kids and Families Registration

Registration Information (Child)

Child's first name: *

Child's last name: *

Child's date of birth: *

Child's gender

Female

Male

Prefer not to disclose

Other

According to the GMFCS scale (see here), my child's rating would be approximately: *

Primary Parent/Guardian Contact Information

First Name: *

Last Name: *

Address: *

City: *

Province: *

Postal Code: *

Home Phone: *

Cell Phone: *

E-Mail (Confirmation e-mail will be sent here): *

E-Mail (Please enter again to confirm): *

Relationship to Child: *

Languages Spoken:

Secondary Parent/Contact Information

First Name:

Last Name:

Same as Primary Parent

Address:

Home Phone:

Cell Phone:

E-Mail:

Background

Child's diagnosis *Check all that apply

My child's height in inches is: *

My child's weight in pounds is: *

Does your child use a wheelchair/stroller? *

Does your child have uncontrolled seizures? *

Other challenges:

What are the biking goals for your child? *Check all that apply

Do you have a current CPKF adaptive bike at home? *

Yes

Where will this bike be stored? *

How will you be transporting the adapted bike to your home? *

Are there any changes that you'd like to see on the bike?What didn't work about the bike you previously had (if anything)

Volunteer with the organization:

Other comments/questions

You will be receiving 2 emails - one confirming that you have been successfully registered and one allowing you to select your specific time for your child's bike fitting. Please watch for these 2 emails.

All information provided and generated by staff will be maintained by the organization in order to ensure continuity in the evaluation process for participants in future years, allow for the best tracking/monitoring of outcomes, and remain confidential. Please note that such information may also be maintained for an indefinite period by the organization in anonymized form for general purposes, including in order to allow for program assessment and improvement, allow for research and/or study, and/or grant and financing application purposes.

Borrow an Adapted Bike Registration Form

Volunteer with the organization: