Lanark Site - Community Programs Registration Form
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Indicates a required field
If you need any assistance with registering, please contact Pam at 613-259-2182, ext. 2306
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What Program/Group are you registering for?:
Select
In-Person: Walking Outdoor WorkOut
Virtual - Fit for Life Active
Virtual - Fit For Life Gentle Balance
In-Person: Guys in the Kitchen
Online format progams use ZOOM (
https://zoom.us/
). Please complete this registration form and more details will be emailed to you regarding participation in our online programs. Please note, you must have high speed internet service with an internet connection – broadband wired or wireless (3G or 4G/LTE). Minimum bandwidth is 600kbps (up/down) and recommended is 1.5 Mbps (up/down). You can check your Internet bandwidth by going to www.speedtest.net. You also need a microphone and webcam (camera built in or attached).
If you do not have all three please do not register for online Programs.
You can call ConnectWell Community Health for more information – 613-259-2182.
If online please confirm you have high speed internet service, a microphone and webcam.
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Family (Last) Name:
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First Name:
Preferred Name (if different from above):
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Date of Birth (Day / Month / Year):
e.g. 12/03/1955
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Street/Road:
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Town/City :
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Province:
Select
Ontario
Alberta
British Columbia
Saskatchewan
Manitoba
Quebec
Prince Edward Island
New Brunswick
Newfoundland and Labrador
Nova Scotia
Yukon
Northwest Territories
Nunavut
Other
Other:
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Postal Code:
Telephone Number (Please provide only numbers where you permit us to call)
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Preferred:
Alternate:
Mobile/Cell:
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Email address:
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Message Allowed:
Select
Yes
No
Message Allowed:
Select
Yes
No
Message Allowed:
Select
Yes
No
Please provide only email that you permit us to use to contact you.
This form has been completed by a third party for individual(s) without an e-mail address, please do not use the above e-mail address to contact them, use the provided Telephone number(s).
Emergency Contact
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First and Last Name:
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Relationship:
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Phone Number:
Privacy
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As a participant of this group, I will respect the privacy and confidentiality of other individuals in the group.
