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You are registering for the Mindfulness Based Stress Reduction (MBSR) Information Session, scheduled for Thursday, September 14, 2023 from 6:30 - 8:30 pm at ConnectWell Community Health - Lanark. If you need any assistance with registering, please contact Kara at 613-259-2182 ext. 2302Name(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 AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Telephone Number (Please provide only numbers where you permit us to call)Preferred(Required)Message Allowed(Required)YesNoAlternateMessage AllowedYesNoEmail(Required) Please provide an email address that you permit us to use to contact you.Emergency ContactName(Required) First Last Relationship(Required) Phone Number(Required)PrivacyAs a participant of this group, I will respect the privacy and confidentiality of other individuals in the group.(Required) Yes
