Family Program Form

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GENERAL INFORMATION

Attendee 1

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone(Required)

Alternate Phone

Email(Required)

How did you hear about the Thorpe Recovery Centre Family Program?

Do you have any relationships – personal or otherwise, with any TRC staff?

Yes

No

Share a bit about that

EMERGENCY CONTACT INFORMATION

Emergency Contact:

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Alternate Phone

Email(Required)

Verbal and or written consent(Required)

No

Yes

Do you have a spouse or children who have or are currently attending Thorpe Recovery Centre?(Required)

Yes

No

Name(s)

Enrollment

Enrolment Date(Required)

Method of Payment(Required)

VISA

Mastercard

E-Transfer

A member of our accounting team will be in touch to finalize payment.

Number of Family Members attending.(Required)

If more than 1 attendee, please complete the following for each addition attendee

GENERAL INFORMATION

Attendee #2

Attendee 2 Name

First Last

Address

Street Address Address Line 2 City Province Postal Code

Phone

Alternate Phone

Email

EMERGENCY CONTACT INFORMATION

Emergency Contact:

Name

First Last

Relationship

Phone

Email

Verbal and or written consent

Yes

No

GENERAL INFORMATION

Attendee #3

Name

First Last

Address

Street Address Address Line 2 City Province Postal Code

Phone

Alternate Phone

Email

EMERGENCY CONTACT INFORMATION

Emergency Contact:

Name

First Last

Relationship

Phone

Alternate Phone

Email

Verbal and or written consent

Yes

No

Close Menu

Home
About
Society Membership
Programs
Admissions
- Criteria for Admissions
- Application Form
Events Fundraising
Alumni
- Alumni Program
- Meetings & Resources
Volunteer
FAQ
Gallery
Careers
Contact

facebook
linkedin
instagram