Required fields are marked with asterisks (*)

Program Participant Form

If you would like to participate in our programs through the WISE Mobile Active Living Centre, please complete the form below. Should you have any questions regarding this form or our programs, please call our Seniors Programs and Services team at 705-645-2100 ext. 4199. Please note that you will need to contact us to register for individual programs of interest. Thank you and we look forward to you joining us!

First Name:

Last Name:

Mailing Address (Including unit number, PO Box, RR if applicable):

Town/City:

Postal Code:

Is your physical address the same as above?

Home Phone Number (landlines only):

Cell Phone Number:

Email Address:

Would you like to receive program information by email?

Yes

Date of Birth:

Would you like to receive a birthday card annually from our Peer Support Committee?

Yes

How did you hear about Seniors Programs and Services?

Emergency Contact Information:

Do you have an emergency contact?

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Program Participant Form

Emergency Contact Information: