Recreation for Life Foundation

First Name (no initials please):

Last Name:

Position / Title:

Organization Name:

Mailing Address:

City: 

Province: (2 Letter Code Only)

Postal Code/Zip Code: 

Phone (Bus.): (999.999.9999)

Fax:  (999.999.9999)

Banquet Choice: Choose One Steak Chicken Fish Vegitarian Other

Handicap:  

Email:

Dietary needs:

Other special needs to fully facilitate your inclusion in the event: