Membership - Equatoria community

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Full Name *

Date *

Gender

Street Address *

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Phone Number *

Email Address *

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Are you registering as an individual or as a family

If family, list the names, ages and relationships of family members0 / 180

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How long have you lived in Canada

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Emergency Contact Full Name *

Emergency Contact Relationship *

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Emergency Contact Alternate Phone Number

Skills or experience you would like to offer the community

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