Change Maker Program Registration Form
By filling out this form you are registering for the 10 week Moncton program taking place from March 11 to May 13th, 2018 at the Venn Centre. We will be in touch with you shortly after the form is submitted! All information is kept confidential and within the organization.

If you would rather fill this out with our office over the phone, or have any questions, please call Rachel at 506-261-6520.

Full Name of Participant:
Your answer
Age of Participant:
Your answer
Contact email (parent):
Your answer
Primary language:
Emergency contact name and number:
Your answer
Health concerns & Dietary restrictions?
Your answer
Preferred method of payment (we will contact you for this information upon confirmation of registration):
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