Registration request for Gambling and Behavioural addictions

Thank you for your interest in this event/program. Please complete and submit the form below.

Timeslot:

Thursday 24th Jun 2021, 6:30pm - 8:00pm

Location:

FHT Office

Capacity:

Although this event is fully booked we are taking extra registrations.

Nom:

Date of Birth:

Parent/Guardian:

OHIP #:

Courrier électronique:

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Numéro de téléphone:

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Médecin:

Message:

1. All your information is treated confidentially.

2. If you are registering on behalf of someone else (e.g. dependent, child), please enter the date of birth and health card of that person.