Re-Entry Program Registration

REENTRY PROGRAM REGISTRATION

Contact and Sponsor information:

Name (required)

Email (required)

Address (required)

Telephone (required)
Cell phone
Name of sponsoring agency (required)

Program fees should be billed to  Sponsor  Participant

Personal and Family information:

Gender  Female  Male
Date of Birth
Post-secondary education

Special interests and/or talents

Spouse's name (if applicable)*

*If your spouse is also going to participate in this Forum program,
he/she must submit a separate registration form.

Did your spouse accompany you on your placement?
 Yes No
Names and ages of children who accompanied you on your
placement (if any)

Re-Entry-related information:

List the countries in which you have served with dates of service
(Please press Enter after each country entry):

Were you in areas where violence was present?  Yes No
If Yes, please describe your experiences (so we can help address
these kinds of situations):

Date of arrival back in Canada (or the United States)

Are you presently in paid employment?  Yes No
If Yes, please describe:

Are you currently looking for paid employment?  Yes No
Are you currently in full-time studies?  Yes No
Please describe any future plans

Travel information:

How are you travelling to the Re-Entry Program (if known*)?

*If you have not made travel arrangements yet, please notify the
Forum as soon as you have arrival and departure information.

Arrival date and time

Departure date and time

Accommodation and Special Needs:

• Accommodation rates are based on double-occupancy.
  If you prefer single-occupancy, and space is available,
  would you pay an additional fee for it?  Yes No
• I would prefer to share a room with
  

Special Dietary and Other Needs:

• I prefer vegetarian entrées only:  Yes No
• Other dietary needs or food allergies (if any)
  
• Other (non-food related) allergies (if any)