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Lanark Site – Community Programs Registration Form
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Lanark Site – Community Programs Registration Form
If you need any assistance with registering, please contact Pam at 613-259-2182, ext. 2306 or Kara at 613-259-2182 ext. 2302
What Program/Group are you registering for?
(Required)
Food Handler Certification Course
Virtual format progams use ZOOM (
https://zoom.us/
). Please complete this registration form and more details will be emailed to you regarding participation in our online programs. Please note, you must have high speed internet service with an internet connection – broadband wired or wireless (3G or 4G/LTE). Minimum bandwidth is 600kbps (up/down) and recommended is 1.5 Mbps (up/down). You can check your Internet bandwidth by going to
https://www.speedtest.net/
. You also need a microphone and webcam (camera built in or attached).
If you do not have all three please do not register for online Programs.
You can call ConnectWell Community Health for more information – 613-259-2182.
If Virtual please confirm you have high speed internet service, a microphone and webcam.
(Required)
Yes
No
Name
(Required)
First
Last
Preferred Name (if different from above)
Date of Birth
DD slash MM slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Province
Postal Code
Telephone Number (Please provide only numbers where you permit us to call)
Preferred
(Required)
Message Allowed
(Required)
Yes
No
Alternate
Message Allowed
Yes
No
Email
(Required)
Please provide only email that you permit us to use to contact you.
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).
(Required)
No
Yes
Emergency Contact
Name
(Required)
First
Last
Relationship
(Required)
Phone Number
(Required)
Privacy
As a participant of this group, I will respect the privacy and confidentiality of other individuals in the group.
(Required)
Yes
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