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2. First Name*
3. Last Name*
5. Address*
7. City*
8. Province*
9. Postal Code*
11. Email Address*
12. Phone Number*
14. Where did you hear about this program?*

    1. Don't Hibernate
    2. Facebook
    3. Friends/Family
    4. Newspaper
    5. Participating Facility
    6. Primary Care Network
    7. Welcome Wagon
16. Freedom of Information & Protection of Privacy (FOIP) Notification Statement
    The personal information that you provide to the City of Lacombe is collected under the authority of the Alberta Freedom of Information and Protection of Privacy (FOIP) Act - Section 33(c). The information will be used for the purpose of registering participants in recreation programs and administration of these programs.
18. Collected personal information is protected from unauthorized access, collection, use, and disclosure in accordance with the FOIP Act, and can be reviewed and corrected upon request.
20. Questions regarding the collection of personal information can be directed to the FOIP Coordinator.
    Contact the FOIP Coordinator
24. To receive a copy of your submission, please fill out your email address and submit.
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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