ONLINE: Group Check-in

* These fields are required

1 Welcome

2 Pay what you can

	CAD $ The suggested amount is between CAD $15.00 and CAD $20.00. You can enter any amount or leave it empty.

3 People in your group

5 Please tell us a bit more about you...

Preferred name	If different than first name - the name you go by.
Pronouns
Phone - cell	Cell or mobile phone.
Phone	Best number to reach you about your registration.
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Terms and Conditions *	I accept the terms and conditions.View terms and conditions. Some online program sessions may be recorded. Audio and visual of participants will not be shared without prior consent.
Email communications	Yes, I agree to receive additional resources, special offers, and occasional updates related to opportunities at The Haven.As part of your program registration, you will receive a few essential emails from us related to your experience. Beyond that, we hope you'll opt in to stay connected. You can unsubscribe at any time.
How did you hear about this program? *	The program leader's website, email, or social media Email from The Haven The Haven's Social Media A friend or family member The Haven's Website During another Haven program Doctor, counsellor or medical professional alive magazine article Other Please check all that apply and provide the name of the person referring you or book perhaps if this applies.
Who were you referred by?	We want to thank them! Please include first and last name and email address.
Dietary Preferences *	Regular Vegetarian Vegan The meal package includes either a regular or vegetarian option. The following dietary restrictions: gluten free, vegan, dairy free and severe allergies can be accommodated.
Dietary Restrictions	List any allergies or sensitivities (including gluten-free and dairy-free), along with their severity.
If you have selected the dorm, do you have a preference between the upper and lower bunk?
Birth Date	A participant must be 19 or older to register for an adult program at The Haven
Gender
Medical Information	Medications, allergies, surgeries, current issues.
Emergency contact	Who should we contact in the event of a personal emergency? Please choose someone who will be available during the program.
Additional rooming information	Examples: request a specific roommate, no stairs, etc.
Emergency contact phone	Phone for your emergency contact.
Emergency contact relationship	This person is my ____.

Continue

6 Payment

Promo code

Sub Total	$0

Donations	$0

Taxes	$0

25% Deposit	$0

Due Now	$0 $0

Remaining Balance	$0

Choose Payment Option

	Interac eTransfer - to accounts@haven.ca Read more about Interac e-Transfer. Click on the button below and these instructions will be repeated on the next page.

First Name
Last Name
Card Type
Card Number *
Card Expiration *	Month Year
Card Security Code	usually a 3 digit code on back of card

Guest 1		First Name* Last Name* Email*
Guest 1	suggested-donation	First Name* Last Name* Email*

1 Welcome

2 Pay what you can

3 People in your group

4 Additional Programs

Participants

5 Please tell us a bit more about you...

6 Payment