Coffee Break Survey

Coffee Break
Attention all coffee & tea enthusiasts!
Join us for a delightful morning caffeine break where everyone is welcome, including your little ones (though children are not required). This is a perfect opportunity to connect with other adults who share similar experiences. Come for the coffee, stay for the community!

Wednesday, January 15
10:00 a.m.-12:00 p.m.
$3 per participant experiencing a deployment
$5 per participant not experiencing a deployment
Location - MFRC
Register & pay by Wednesday, January 8

Question Title

* 1. Are you:

Regular Force / family

Reservist / family

Veteran / family

Other - please specify:
1. Public Service Employee
2. CFMWS (PSP, NPF) Employee
3. Family within an 8km radius of Shilo

Question Title

* 2. Is your family experiencing a deployment?

Yes

Question Title

* 3. Participant's Information

Name:

Cell phone number:

Alternate phone number:

Email Address:

Question Title

* 4. Do you have any allergies or specific medical concerns?

Yes

If you have answered yes, please give details

Question Title

* 5. Acknowledgment:

I acknowledge that, in case of an emergency, the staff of the Shilo MFRC will secure medical advice and services as deemed necessary for the health and safety of anyone participating in Shilo MFRC programs. The Shilo MFRC does not assume financial responsibility for any cost associated with seeking medical advice.

Question Title

* 6. Do you grant permission to the Shilo MFRC, its agents, and employees, the right to photograph you and/or your minor child registered for this program for use in any MFRC publication including print, web sites or other electronic form of social media.

Yes

Question Title

* 7. How did you hear about this program? Please indicate your main source

MFRC Newsletter

MFRC social media (FB or IG)

Poster

Shilo Community Guide (base TVs)

MFRC Website (www.cfmws.ca)

Shilo MFRC Spills the Tea (deployment email)

From a friend

Other (please specify)

Question Title

* 8. FOR OFFICE USE ONLY - DO NOT COMPLETE

Date:

Amount Paid:

Receipt #:

Staff Name: