REGISTRATION FORM - FIBROMYALGIA SUPPORT NETWORK

Contact Relationship 2-part

Your FULL Name *

First

Last

Your Email Address *

Your Contact Number *

Is this contact number your *

Cell/Mobile
Landline

Your Street Address including House/Apartment No. *

City/Town In Which You Live *

Province/Territory *

Postal Code

I would like to register for the "Living A Health Life with Chronic Pain Workshop Series"

Please select ONE session option only. By submitting this registration form, you are committing to attend ALL SIX SESSIONS unless you fall ill. NOTE: Where possible, we will strive to accommodate any special needs or accommodations requested.

I am (copy) *

a person living with fibromyalgia
a person living with chronic pain not caused by fibromyalgia
a person interested in learning more about chronic pain

I would like to register for FM101: I've Been Diagnosed with Fibromyalgia, Now What 2-part Seminar

I am *

a person living with fibromyalgia
a family member/caregiver of someone living with fibromyalgia
a person interested in learning more about fibromyalgia

Please Register My Guest Who Will Join Me In The Workshop Series and/or Seminar:

First

Last

Guest Email

Relationship to Person with Fibromyalgia:

Spouse/Partner/Significant Other
Son/Daughter
Friend/Other Caregiver

My guest will join me for:

Living A Health Life with Chronic Pain Workshop
FM101: I've Been Diagnosed with Fibromyalgia, Now What? Seminar

Please select all that apply to your guest's attendance.

Questions, Comments or Message?