* indicates a required field

*Occupation: Teacher  Principal  School Administrator Public Health Rep	Other:
*Salutation: Mr.   Mrs.   Miss   Ms.
*First Name:	*Last Name:
*School Board:	*School/Organization:
*School Address:	*City/Town:
*Province: Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon	*Postal Code:
*Telephone:	Fax:
*E-mail:	Preferred communications: Telephone  Fax  E-mail

*Total number of students in school:

Number of students per grade who will be participating in the program:

K 1 2 3 4 5 6 7 8

*Number of teachers using Take Action:

K 1-3 4-6 7-8

*Where did you hear about the Take Action program? Colleague(s) Flyer/letter sent to my school At a conference (please specify) I’ve used Take Action before Ophea website Other (please specify)

By providing Ophea with personal information on this Registration Form, you are consenting to Ophea collecting and using it to contact you regarding this and other Ophea initiatives. Ophea does not sell or share any personal information collected with other organizations in accordance with Ophea's Privacy Policy.