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Profil number - Child

Pour le français, cliquez ici.

Personal information contained on this form is gathered under the authority provided by the Right to Information and Protection of Privacy Act (RTIPPA) and the Personal Health Information Privacy and Access Act (PHIPAA). Personal information will be used to determine your eligibility for programs offered by the City of Dieppe insofar as issuing a profile number is concerned. It will also be used to communicate with participants if authorization is given. Contact the Office of the Clerk of the City of Dieppe at 877.7900 for any questions regarding the gathering of this data.

63CLV07.18

First name

Last name

Gender

Female

Male

Preferred language

French

English

Date of birth

Address

City

Province

Postal code

In order to be able to provide proper guidance to your child during leisure activities offered by the City, we need you to tell us if your child requires special care at home, during extracurricular or leisure activities. For example: special diet, intolerance or allergies to products or medicines, special health needs, disability, phobias, etc.

Special care required?

Yes

If you answered yes, the activity coordinator will contact you for more information.

First name (parent/guardian)

Last name (parent/guardian)

Gender (parent/guardian)

Female

Male

Date of birth (parent/guardian)

Home phone

Phone number parent/guardian (work)

Phone number parent/guardian (cell)

Email address

Address (if different from the one mentioned above)

Contact in case of emergency

Name

Home/work telephone number

Cell number

Dieppe residents: After receiving your profile number via e-mail, visit the Aquatic and Sports Centre or City Hall to show proof of residence.