Program Registration

Break Free Family Centre

Program Registration

Please select the program / services you are registering for:

Change Youth Justice Program Transitioning Youth Counselling BFFC Group Counselling Program

Other Couselling Services (Please specify):

____________________________________________________________________________________________

First Name

M.I.

Last Name

Home Address

City

Province

Postal Code

Primary Telephone No.

Primary Language Spoken

Date of Birth

Gender

Male Female Nonbinary

Questions about the collection and use of personal information should be forwarded to which email.

Thank you for your interest in joining the Breakfree Family Centre. Our which director will review your application and get back to you. If you have any questions in the interim please feel free to contact the which director at which email.

Important Notice

Privacy Statement: Personal information is collected under the statutory authority of the Occupational Health and Safety Act. Personal information on this form will be used to determine suitability for volunteer initial and on-going placements, as well as program evaluation and assessment.

Please read carefully before checking the box below: By checking this box I hereby certify that all of the information that I have provided in this application is accurate and true and I understand that any false or misleading statements or deliberate omissions made by me on this application or during the membership recruitment and selection process may be sufficient cause for the cancellation of this application and, for the immediate termination of my membership.

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Program Registration

Break Free Family Centre