Women and Children Program Registration

Choose Program
Choose Session
Children's Information
How many children do you need to register?
Child 1 Name
First Last
Child 2 Name
First Last
Child 3 Name
First Last
Address
Street Address Address Line 2 City Province Postal Code
Child 1 Date of Birth
MM slash DD slash YYYY
Child 2 Date of Birth
MM slash DD slash YYYY
Child 3 Date of Birth
MM slash DD slash YYYY
Health Information
Any allergies, asthma, medical concerns or dietary restrictions we should be aware of?
Parent/Gaurdian Information
Name
First Last
Relationship to Child
Email
Enter Email Confirm Email
Phone
As a participant, I agree to to follow Women’s Habitat’s Code of Conduct
How did you hear about the program?