REENTRY CONFERENCE REGISTRATION Contact and Sponsor information: Name (required) Name you prefer to be called by (if different than above) Email (required) Mailing address (required) Telephone (required) Alternate phone Name of sponsoring agency/denomination (required) Program fees should be billed to SponsorParticipant Personal and Family information: Gender Decade in which you were born Post-secondary education Did a life partner, spouse, significant other accompany you on your placement? YesNo Was your placement a time of separation from a life partner? YesNo If your partner is also registering for this program, what is their name? *If your partner is also going to participate in this program, they must submit a separate registration form. Names and ages of children who accompanied you on your placement (if any) Re-Entry-related information: List the countries in which you have served with dates of service and brief description of the work or ministry. (Please press Enter after each country entry): Were you in areas where violence was present? YesNo If Yes, please briefly describe your experiences: (to help us adapt the reentry program to the participants' experiences) Date of arrival back in Canada (or the United States) Are you presently in paid employment or full time studies? YesNo If Yes, please describe: Are you currently looking for paid employment or are registered for studies in the near future? YesNo Are you retired or retiring from full time paid work? YesNo Please briefly describe any future plans: Briefly, describe any issues or experiences of your placement or re-entry for which you would hope this program will provide space for reflection or conversation? Travel information: How are you travelling to the Re-Entry Program (if known)? Will you require parking while at the program (for overnight parking we need to pre-book spaces) YesNo Accommodation and Special Needs: Accommodation will be a single room unless otherwise indicated. Do you prefer a double room with your partner also participating in the conference? YesNo Name of person sharing room with you: Special Dietary and Other Needs: Please describe any mobility or other ability issues: I prefer vegetarian entrées only: YesNo Other dietary needs or food allergies (if any) Other (non-food related) allergies (if any) Once you click "submit registration" watch below for a confirmation. There will be a message below to confirm successful submission of this form or you will be asked to resubmit with missed information. An automated email will be sent to confirm that we have received your registration.