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 Program Registration Form
The Building Blocks of Self-Care
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Surname * First Name *
Age Address* City *
Postal Code * E-mail *
Telephone: Home * Work / Cellular
Language Preference: *
English French French or English
* Please list all your
chronic conditions
* Where did you hear
about the program?

Have you ever been seen by a health care professional at any of the McGill University Health Centre (MUHC) hospitals?(Hospital: Montreal General, Royal Victoria, Montreal Neurological, Lachine, Chest Institute, Montreal Children’s’)

*

Day or time preferred (The 2 ½ hour workshops are held once a week for six consecutive weeks.
Please indicate your preferences below with the numbers: 1, 2, 3, 4

Preferred Day

*
Tuesdays
*
Wednesdays
*
Thursdays
*
Week‐end (Saturday or Sunday)
Preferred Time
*
Morning (e.g.; 10h00 – 12h30)
*
Afternoon (e.g.; 14h00 – 16h30)
*
Evening (e.g.; 18h15 – 20h45)

For security reasons, please enter the characters in the image into the text box :

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To register, please fill out the registration form above then click on "Submit" below.


Form Designed and Programmed by Marcus Arts and Marc-Andre Meloche

Neuro Media Services MNI