Skip to content
Activities
Events
Membership
Gallery
Wellness
Newsletter
Contact
Registration
Register
Contact Information
Membership
Nametag
0% Complete
1 of 3
Contact Information
Name
*
Name
First Name
First Name
Last Name
Last Name
Nickname
Date of Birth
*
Phone
*
Cell Phone
Email
*
Gender
*
Male
Female
Address
*
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Emergency Contact Information
Name
Name
First Name
First Name
Last Name
Last Name
Relationship
Phone
Name Tag Order
Name as you want it to appear on Name Tag
If you have a preferred Nickname, please enter it in this field
Type of Name Tag
Pin ($15 Each)
Magnetic ($15 Each)
Replacement ($15 Each)
Extra ($15 Additional)
Payment
Cash
Cheque
E-Transfer
If Paying by Cash or Cheque, Please drop of at East Ferris Golden Age Club in Treasurers Box. E-Transfers can be sent to efgactreasurer@gmail.com
Comments
Languages Spoken
English
French
Other
Other
Language preferred
*
English
French
Other
Other
Were you ever an East Ferris Resident
*
Yes
No
If you are human, leave this field blank.
Next
Page load link
Go to Top
