Staff Information Form Your Name* First Last Your primary email address* Your primary phone number*Your mailing address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Emergency contact name First Last Relationship to emergency contact*Emergency contact primary phone number*Emergency contact secondary phone number (if available)Health card number*Have you had / do you have any of the following health issues: Allergy to food? Allergy to medication? Other allergies? Type 1 Diabetes? Epilepsy? Celiac disease? Other physical health concerns you would like us to know about? Other mental health concerns you would like us to know about?? Please explain the allergic reaction and the treatment requiredPlease describe these physical / mental health issues and their treatmentHow is your insulin delivered?*PumpInjectionsDo you regularly take medication?*YesNoPlease list all medications, dosing information, and reason for takingWith my signature below, I certify that all information provided on this form is, to my knowledge, accurate and complete.* This iframe contains the logic required to handle Ajax powered Gravity Forms.