2012 Communities ChooseWell Registration Form

1. Community or Municipality Name *This question is required.

2. Population of your Community or Municipality: *This question is required.

3. Contact Information of ChooseWell Leader

First Name *This question is required.

Last Name *This question is required.

Position Title

Organization Name

Mailing Address *This question is required.

Street Address

City *This question is required.

Province *This question is required.

Postal Code *This question is required.

Email Address *This question is required.

Primary Phone Number *This question is required.

Other Phone Number

Fax Number

4. Information collected will be protected in compliance with Canada's Personal Information Protection and Electronic Documents Act, and the Freedom of Information and Privacy Protection Act. Some information collected may be shared with other participants, community members, partners, and sponsors in compliance with the above Acts through such means as posting on the Communities ChooseWell website or sharing in newsletters, networking lists, etc. This information is being collected for the purpose of communicating about Communities ChooseWell and providing materials to support your participation, as well as to create online community profiles to facilitate broad community participation and sharing of practices. Please note that stories, reports, photographs and videos submitted by participants may be posted on the Communities ChooseWell website and used for promotional purposes by Communities ChooseWell. Please indicate if you agree to the above statement. If you do not agree, your information will not be shared. For additional privacy information please contact us at 1-877-544-1747. *This question is required.

2012 Communities ChooseWell Registration Form

General Information