top of page

Register

Personal Information

First Name

Last Name

Email

Phone

Are you a Permanent Resident?

Yes

No

Are you a Canadian Citizen?

Yes

No

Are you Indigenous/Aboriginal?

Yes

No

If you are NOT a Canadian citizen, what is your country of origin?

If you answered YES to Permanent Resident, what is your Permanent Resident #?

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Birthday

Manitoba Health Card Number (9-digit)

Name Of Emergency Contact

Phone Number of Emergency Contact

Parent/Guardian Information (if under 18)

First Name

Last Name

Relationship to Participant

Address (if different )

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Additional Information

How did you find out about this program?

What do you wish to learn from this program?

bottom of page