Course Registration Form

Registration Form

Fill out the form carefully for CLC Huron-Perth Christopher Leadership Course registration.
Student Name*

First NameLast Name
I am 16 years or older. (Students must be 16+. If you wish to attend and are under 16, please email clccoursehuronperth@gmail.com)*

Yes
Age Group
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
E-mail*
example@example.com
Mobile Number*
Work Number
Company
I agree to be contacted with course updates.*

Yes
What is your preferred method of contact*
Method of Payment*
How did you hear about us?*
I agree to pay the course cost of $175 on the first day of the CLC 1 course and that this is not refundable.*

Yes
This course takes place Monday evenings from 7 pm - approximately 9:30 pm beginning Monday October 20 at Spruce Lodge (643 W Gore St, Stratford, ON N5A 1L4)*

Confirm
Additional Comments or Questions
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