Registration Form

Please complete this form to show interest in attending one our 15- week Life Skills Programs. Once this form is submitted, we will contact you to go over a few things and confirm your registration. 

Fort Macleod Registration Form

– Step 1 of 6

Name *

First

Last

Date of Birth *

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Gender *

• Female
• Male
• Non- Binary
• Prefer Not to Say
• Transgender
• Two Spirit
• X
• Other

Marital Status *

• Single
• Married
• Common Law
• Divorced
• Separated
• Widowed

Number of Dependents *

Were you referred to us by a community agency? (For example: a doctor, counsellor, treatment program, court, etc.) *

• Yes
• No

If you answered "Yes" to the question above, please provide us details of who referred you. *

Next

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Next

Do you have any medical conditions or history that would interfere with the program during the 15- weeks? *

• Yes
• No

Please provide us details and if you will need assistance during the 15 weeks. *

Are you currently taking any medications? *

• Yes
• No

Please provide us details on the medications. *

Do you have any allergies? *

• Yes
• No

Please provide details on you allergies and how severe they are. *

Do you carry an auto- injector (EpiPen)? *

• Yes
• No
• Sometimes

Next

Emergency Contact # 1: Name *

Emergency Contact # 1: Phone *

Emergency Contact # 1: Relationship *

Emergency Contact # 2: Name *

Emergency Contact # 2: Phone *

Emergency Contact # 2: Relationship *

Next

Participant Agreement

1) Remember what is said by other participants doesn't leave the program, all information is private and not to be shared outside of the program. *

• I agree
• I do not agree

2) Please do not gossip about other participants inside or outside of the program *

• I agree
• I do not agree

3) Please either turn cell phones off or on silent. If you are expecting an important phone call, please let the program staff know and take the call outside of the room. If phones are deemed a distraction, the program staff may ask you to no longer have your phone with you or ask you to give your phone to the program staff for the day.

• I agree
• I do not agree

4) The program will start at 8:30AM and end at 3:30PM every day, please be on-time and prepared to stay for the entire day. *

• I agree
• I do not agree

5) Please be aware of how you are talking, for example your tone or choice of words (swearing is not allowed during the program). This also includes allowing others to have a chance to speak and not having side conversations when others are talking. *

• I agree
• I do not agre

6) Please remain in the room during the entire, there will be breaks. If you need to step out, please let the program staff know. *

• I agree
• I do not agree

7) Please be aware of other participants boundaries, physically, mentally, emotionally, and spiritually. We all have different boundaries so we all need to be respectful. *

• I agree
• I do not agree

8) Please be aware of your hygiene and body odors, other participant maybe be sensitive to certain smells, this includes perfume/cologne and cigarettes smells. *

• I agree
• I do not agree

9) If you no longer wish to be a part of the program, you must let the program staff know and they can process your departure from the program. *

• I agree
• I do not agree

10) The program facilitators can use their discretion and discharge anyone from the program if they deem it necessary and appropriate. This could be for the day or for the remainder of the program. *

• I agree
• I do not agree

11) Abusive and threatening language and/or behaviour will not be tolerated. You will be asked to leave for the remainder of the program if the program staff feel like you are a risk to others. *

• I agree
• I do not agree

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