Online Registration Form:

This is an online registration form for courses offered by UNB Campus Recreation. After you submit this form, a Campus Recreation staff will review your registration information. Once your information is confirmed you will receive an email confirmation. If you have any questions please contact UNB Campus Recreation at 453-4579 directly.

Disclaimer

UNB Campus Recreation takes security of your personal information seriously. Your personal information will be stored in Campus Recreation Database and we only use that information to process your program registration requests. Moreover, we do not create individual profiles with the information you provide to any private organizations. UNB Campus Recreation does not collect information for commercial marketing.

I have read the above disclaimer.

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Personal Information
*	Have you ever registered before?  Yes No
*	First Name:
*	Last Name:
*	Status:	[Select ...]   Student   Faculty/Staff   Alumni   General Public   Youth   Note: for children swim class, please select "Youth" here.
*	Sex:	[Select ...]   Female   Male
	Age:
*	Email Address:
*	Primary Phone:
	Secondary Phone:
	Guardian Info:
	Additional Information:
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Course Selection
*	Course starting from:	[Select ...]   2010 August   2010 September   2010 October   2010 November   2010 December   2011 January   2011 February   2011 March   2011 April   2011 May   2011 June   2011 July
*	Select a course:	[Select ...]
	Days:
	Time:
	Location:
	Enrollment:
	Instructor
*	Fee Type:	[Select ...]
	Fee Amount:
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Par-Q Form (for Non-swimming)
	1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?	Yes  No
	2. Do you feel pain in your chest when you do physical activity?	Yes  No
	3. In the past month, have you had chest pain when you were not doing physical activity?	Yes  No
	4. Do you lose your balance because of dizziness or do you ever lose consciousness?	Yes  No
	5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?	Yes  No
	6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?	Yes  No
If you answered YES to one or more of the questions, your doctor's approval is required before you participate in the program.
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Application Agreement

I, the undersigned, do hereby acknowledge: My consent to take part in a recreation program offered by the University of New Brunswick Campus Recreation Program; My understanding that there are potential risks including permanent injury, minor or serious, including permanent disability,and that these types of injuries may result from the actions or inactions of others or a combination of both, and that I, assume willfully these risks.

Name of participant:    Date: September 03, 2010

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Note: all entries labelled with * are required.

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