AAQITAUVIK

Steps To Freedom Registration Form

* Required

Thank you for applying to Aaqitauviks’ Steps to Freedom Program.
This is an approximate 3 week program, with sessions focusing on healing from past trauma, wounding and resulting addictions.
Each Applicant is responsible to arrange and provide their own flight, housing and financial needs while they are staying in Quaqtaq for the Program.
During this time, you will attend each session Monday-Friday, where daily attendance will be taken. A general report will be given to Lawyer or Social Services where necessary.

** Required. Please write a short email to Aaqitauvik stating why you feel this program will benefit you.

If you have further questions, you can contact our office at 819-492-9145 or email us at manager@aaqitauvik.ca

Name of Event:

Location*:

Dates*:

Name of Registrant*:

Address:

# and Street Name/PO Box*:

Community*:

Province*:

Postal Code*:

Telephone #*:

Email*:

Date Of Birth:

Gender:

Marital Status:*:

Single

Married

Separated

Divorced

Contact Person for Social Services / Lawyer

Contact Name:*

Contact Email:*

Contact Telephone #:*

Reason for incarceration:*

Address During Event (If known):

Host/Hostess:

# and Street Name/PO Box:

Community:

Province:

Postal Code:

Phone # of Host/Hostess:

Emergency Contact:

Name*:

Relationship to You*:

Telephone #:*:

Consent: AHC would like to use to use your testimony of what has taken place in your life through this workshop/conference. Your name or photo will not be used. Please sign your name below to consent to your full/part testimony, being used for promotional purposes.

Name*: