Your Name *

First Name

Last Name

Your Phone Number *

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Your Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

*

This project runs for 6 sessions 6th November - 11th December. Are you able to attend at least 4 of the 6 workshops dates?

Yes

No

In Case of Emergency (ICE) Contact Name *

First Name

Last Name

ICE Contact Phone Number *

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