*1.Name (First and Last)(Required.)

2.Preferred Name (if different from above)

*3.Email Address (For event updates and confirmation)(Required.)

4.Affiliation (if any) (e.g. disability organization, advocacy group, etc.)

*5.Which Town Hall would you like to attend?(Required.)

Edmundston

Campbellton

Tracadie

Moncton

6.Do you identify as a person with a disability?

Yes

No