West Hants Regional Municipality

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Contact Information Note: Red text indicates required fields.

Billing First Name:

Billing Last Name:

Address 1:

City:

Postal/Zip Code:

Phone 1:

Phone 2:

Email:

Client #:

Account Information

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Extra Information

Birthdate:

Gender Identity:

Gender Pronoun:

Emerg. Contact:

Emerg. #:

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Medical Information

Do you have any of the following conditions or requirements?:

Allergies:		Yes		No	Epi-pen Required:		Yes		No
Other Medical Conditions:		Yes		No

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