Online MIM Registration

Minds in Motion Registration

This information will be used in the event a Minds in Motion session has to be rescheduled or cancelled. Please complete this form once per household.
Participant Name *

First Name Last Name
Additional Participant Name(s)
Other people in your household who will also attend
Address *

Street Address

Street Address Line 2

City Province

Postal Code
Cell Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
E-mail *
Waiver

Thank you for joining us via Zoom! We are excited to be able to connect with our clients during these times of self-isolation and social distancing – we know staying connected is so important. Please note that we are using Zoom, an online technology that helps us connect with you securely. We believe that privacy measures put in place by Zoom will protect your privacy but urge you to also take steps to protect your privacy, such as using secure wifi, and being aware of your surroundings. Also, since we are working from home, please be assured we have taken every measure to ensure your privacy is respected from others who are social distancing with us!
Accept waiver: *

I accept I do not accept
Comments:
Enter the word as it's shown *
Should be Empty:

Minds in Motion Registration