Required fields are marked with asterisks (*)

Program Participant For

WISE Mobile Active Living Centre offers free programming for residents in Muskoka 55+. If you would like to participate in our programs through the please complete the form below. WISE 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:

Please provide your Mailing Address within the Muskoka region (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?

Form Builder

Program Participant For

Emergency Contact Information: