Username:*                                 Password:*            (max 8characters )

First Name: *          Last Name: *         

e-mail: *                      Confirm e-mail: *        

Gender:*               Female    Male                                  Birthdate: *         (Month, DD, YYYY)

Address: *                   Phone # : *        e.g (514)878-9821

HealthCard#:*                                        SIN: *