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Soutien aux ainé.es -Vieillir en santé
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First Name
*
Last Name
*
Phone Number
*
Email
*
Referred by:
Gender:
*
F
M
Other
Native country:
*
Status:
*
Canadian Citizen
Permanent resident
Refugee/Protected person
Other
If other, please specify
Preferred language of communication
French
English
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Age
*
55-65
65 and over
Dans quelle langue officielle préfériez-vous être servi?
*
French
English
Dans quel format d'activités préfériez-vous être servi?
*
En présentiel
En ligne
Noter que certaines activités requièrent une présence physique
Would you like to be contacted for other services offered by CICAN?
*
Yes
No
Other information:
By filling out this form, you agree to share your data with us. All data collected will be used only for the purpose of this booking and will not be shared with any third party unless you explicitly authorize it.
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