Windsor Prime Experience

Windsor Vistas Request for Information
Please complete this form as acurately as possible, you will be contacted by a representative who will assist you in choosing the appropriate classes based on your experience. You may include any additional notes, comments, or questions to us in the box provided below in the Class Information section.
Last Name:		First Name:
D.O.B. (yyyy/mm/dd):

Address Street:		City:
Prov:		Postal:
Phone:		E-Mail:

CLASS INFORMATION
Please refer to our services page for a list of our classes and schedule times. Include the class name and preferred day and time in the box below. You may also include in this box any other information pertaining to this request for information. A representative will review this, check for class availability, then you will be contacted in response of your request and/or to complete your registration.


HEALTH INFORMATION
1st Contact:		Relationship to participant:
Day phone:		Evening phone:
2nd Contact:		Relationship to participant:
Day phone:		Evening phone:
Emergency Contact:		Relationship to participant:
Day phone:		Evening phone:

Family Doctor:		Phone:

Medications:

Does the participant carry and know how to administer medication(s)? Yes No

Allergies:


Previous injuries:


Other Conditions (braces, contacts, etc):

2996 Deziel Drive, Windsor ON CANADA N8W 5H8 ph: (519) 948-4FUN (4386) e-mail: info@wpx4fun.com