Privacy Statement: We do not use or disclose personal information for any purpose other than those for which it was collected, except with consent or as required by law. Personal information is retained only as long as it is necessary for the fulfillment of the purposes for which it was collected, or as required by law.


*Required Fields.

Honorific
First Name*

Last Name*
Birthdate*
Apt #


Street Address*
City*


Province*
Postal Code*
Phone number*


Ext

Alt number
Ext
Email Address

Who should we contact in event of an emergency?

Full Name*
Relationship to you*
Phone Number*


What programs would you like to take part in?



Do you have MSP?

I agree to abide by the 411 Seniors Centre’s Standard of Behaviour, which reads: “The 411 Seniors Centre is committed to providing a meeting place where everyone is safe and is treated with courtesy, dignity and respect. Behaviour which is discriminatory, violent or threatening will not be tolerated.”

I am aware that by providing my e-mail address, it will be added to our mailing list. I will be sent monthly program schedules, AGM notices, and updates.