2012 Communities ChooseWell Registration Renewal

1. To renew your registration for 2012, please select your community or municipality from the list of 2011 participating communities below: *This question is required.

2. Were you the ChooseWell Leader in 2011? *This question is required.

If you answered "Yes" to the last question and your contact information has not changed, please skip the next question. Otherwise, please update your contact information as necessary.

3. Contact Information of ChooseWell Leader

First Name

Last Name

Position Title

Organization Name

Mailing Address

Street Address

City

Province

Postal Code

Email Address

Primary Phone Number

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 Renewal

General Information