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Renfrew County Sites – Walking Program Registration Form

Name(Required)

First Last

Prefered Name (if different from above)

Date Of Birth( Month/Day/Year)(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Telephone Number ( Please provide only numbers where you permit us to call)

Prefered Phone(Required)

Message Allowed(Prefered)(Required)

Alternate Phone

Messsage Allowed(Alternate)(Required)

Mobile/Cell

Message Allowed(Cell)(Required)

Email(Required)

Third party

This form has been completed by a third party for individual(s) without an e-mail address, please do not use the above e-mail address to contact them, use the provided Telephone number(s).

I give Health Centre staff permission to send me information by mail(Required)

Emergency Contact

First and Last Name(Required)

Relationship(Required)

Phone number(Required)

Is this the first time you have participated in one of our programs?:

Privacy Statement(Required)

As a participant of this group, I will respect the privacy and confidentiality of other individuals in the group.

Renfrew County Sites – Walking Program Registration Form

Telephone Number ( Please provide only numbers where you permit us to call)

Emergency Contact

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