Power Up! Registration Form
  1. Power Up! Registration Form

  2. PARTICIPANT INFORMATION
  3. First Name(*)
    Please let us know your name.
  4. Your Last Name(*)
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  5. Which school do you attend?
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  6. Your Email(*)
    Please let us know your email address.
  7. Please enter your complete mailing address and postal code(*)
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  8. MEDICAL INFORMATION
  9. Yukon Health Care Card Number:(*)
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  10. Name of Emergency Contact Person(*)
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  11. Primary Telephone Number of Emergency Contact Person(*)
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  12. Secondary or Alternate Telephone Number of Emergency Contact Person
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  13. Do you have any existing medical conditions which would affect your ability to participate?

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  14. If Yes, Please Describe
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  15. Do you have any Allergies?

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  16. If Yes, Please Describe
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  17. Do you have any special needs (physical, language, etc.) that will require support ?

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  18. If Yes, Please Describe the needs and he support required.
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  1. LIABILITY & MEDICAL RELEASE

    I hereby agree to release Government of Yukon, Yukon Women in Trades and Technology (hereafter referred to as “the organizers”) it’s representatives, agents, servants, volunteers, and employees from liability for any injury to the named person, resulting from any cause whatsoever occurring to the named person at any time while attending POWER UP!, including travel to and from these activities, excepting only such injury or damage resulting from willful acts of such representatives, agents, servants, and employees.

    I do voluntarily authorize the organizers, their representatives, agents, servants, volunteers, and employees to obtain routine or emergency diagnostic procedures and/or routine emergency medical treatment for the named person as deemed necessary in medical judgment.

    I agree to indemnify and hold harmless the organizers, their representatives, agents, servants, volunteers, and employees for any and all claims, demands, actions, rights of actions, and/or judgment by or on behalf of the named person arising from or on account of said procedures and/or treatment rendered in good faith and according to accepted medical standards.

    PHOTO RELEASE

    I agree that still photographs and videotapes of me taken during the course of the POWER UP! workshops may be used and reproduced by the organizers and their assigns and licensees from any liability in relation to using my image including claims for either invasion of privacy or libel.

    AGREEMENT TO PARTICIPATE/ BE PHOTOGRAPHED/ WAIVER

    I have read and understand the liability, medical and photography releases and by clicking on the "AGREE" button below both the participant and their legal guardian or parent agree to them.

  2. Anti-Spam
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