2017-2018 PEC Youth Centre Member Registration
The PEC Youth Centre is located at 299 Main Street, Picton

If you NEED a RIDE HOME, LET US KNOW! We will help with cab fare.

If you have any questions call 613-476-1462 or contact info@theroc.ca

With this registration, you will be included on ROC e-info shares for Youth Centre programs, events and opportunities.
With this registration, you give media consent for any images/video/recordings taken of you to be used for media purposes, including both traditional and digital or social promotional presentations and marketing campaigns.

Member Information
Last Name:
Your answer
First Name:
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age:
Your answer
Gender
Your Email Address
Your answer
Your Contact Number
Your answer
Is this a cell / text number?
What town are you from?
What grade are you in?
Emergency Contact Information
Emergency Contact Name
Your answer
Emergency Contact Phone Number:
Please provide a number where they can be immediately reached (example: cell phone)
Your answer
Relationship to you:
Your answer
Parent/Guardian Information
Parent/Guardian Name:
Your answer
Phone Number:
Your answer
Additional Information
Have you participated in ROC programs before?
Were you a Youth Centre Member last year?
If you answered "yes" to either of the questions above, What is your reason for returning?
Your answer
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