Member Information Collection Form

First Name:

Last Name:

Work Phone:

Home Phone:

Email Address:

Do You Speak English:
No Yes

Do You Speak French:
No Yes

Other Spoken Languages:

Do You Read English:
No Yes

Do You Read French:
No Yes

Other Written Languages:

How Would You Like to be contacted for upcoming events:
Email Telephone

If we're bring print material to a discussion; what format would you find most Useful:
Standard - 12 point font Large Print - 24 point font Grade 2 Braille

Age:
17 or Below 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 Or Older

Transportation:
I have my own means of transportation I would need a car pool

What Part Of Town Do You Live In:
Aylmer Cumberland Gloucester Gloucester South Goulbourn Kanata Nepean Osgoode Ottawa -Downtown Core Ottawa Rockcliffe Park Vanier West Carleton Hull Gatineau