Registration request for Falls Prevention Education Classes

Thank you for your interest in this event/program. Please complete and submit the form below.

Timeslot:

Wednesday 23rd Sep 2020, 10:00am - 11:30am

Location:

Virtual Mtg

Availability:

20 spaces remaining

Nom:

Date of Birth:

Parent/Guardian:

OHIP #:

Courrier électronique:

Confirmer le courriel:

Numéro de téléphone:

Address Line 1:

Address Line 2:

Town/City:

Province:

Postal Code:

Médecin:

Message:

1. All your information is treated confidentially.

2. If you are registering on behalf of someone else (e.g. dependent, child), please enter the date of birth and health card of that person.