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* 1. Are you a Survivor of the Mohawk Institute?

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* 2. First and Last Name of Mohawk Institute Survivor (and/or name of organization & contact person)

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* 3. Years Attended the Mohawk Institute

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* 4. Name of support person attending the event with you. If unknown at this time please put To Be Determine (TBD). 

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* 5. Is your support person also a Survivor of the Mohawk Institute?

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* 6. I would like to register for the following travel and accommodations assistance. 

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* 7. I require additional accomodations, please describe (wheelchair accessible room, additional room for my support person, Flights etc.)

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* 8. Complete mailing address (Address, City, Postal Code). Required for travel and accomodations assistance. 

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* 9. Email

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* 10. Phone Number

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* 11. Additional comments or questions. For more information please contact info@survivorssecretariat.ca. Once you bit the DONE button your registration is complete and someone will be in touch in the coming week. 

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