Event Registration Form

Please join the Ontario Regional Cancer Program and the Métis Nation of Ontario for an information session on breast cancer screening. Bring your “breast” friend for an informative session! A delicious meal will be served. Prizes to be won!
*Registration is Mandatory as seating is limited.

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* 1. Name:

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* 2. Email:

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* 3. Phone:

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* 4. Are you a Métis Nation of Ontario Citizen?:

Yes

First Nation or Inuit

None of the above

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* 5. Are you between the ages of 40 and 70?

Yes

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* 6. Do you follow any of the these dietary restrictions? (Please select all that apply.)

Vegan

Vegetarian

Religious Dietary Restrictions (e.g., Kosher, Halal)

Gluten Free

Lactose Free

Weight Loss Diet (e.g. Keto, Low Sugar, Weight Watchers)

Low Salt

Food Allergy (e.g. gluten free, peanut free)

Other (please specify)

I do not follow any of these dietary restrictions

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* 7. Have you had a mammogram in the past?

Yes

Event Registration Form

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* 1. Name:

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* 2. Email:

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* 3. Phone:

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* 4. Are you a Métis Nation of Ontario Citizen?:

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* 5. Are you between the ages of 40 and 70?

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* 6. Do you follow any of the these dietary restrictions? (Please select all that apply.)

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* 7. Have you had a mammogram in the past?

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* 8. What City do you live in, closest city if rural.