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If you need any assistance with registering, please contact Pam at 613-259-2182, ext. 2306 or Kara at 613-259-2182 ext. 2302I would like to register for the following:(Required)( choose only one please) ConnectWell Community Health - Lanark, Mondays and Wednesdays 9:00 - 10:00 am (10 items remaining) ConnectWell Community Health - Lanark, Mondays and Wednesdays, 10:15 - 11:15 am (10 items remaining) Zion Memorial Church - Carleton Place, Tuesdays and Thursdays, 2:15 - 3:15 pm (20 items remaining) Snow Road Hall, Wednesdays, 11:00 - noon (15 items remaining) Name(Required) First Last Preferred Name (if different from above) Date of Birth(Required) 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