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Username
*
Email
*
Password
*
Confirm Password
*
First Name
*
Last Name
*
Date of Birth (dd-mm-yyyy)
*
Date of Birth
*
Please Note. This program is for youth between the ages of 12 and 30.
Phone Number
*
Address
*
Address
*
Please confirm that your primary address is within Restigouche County (Belledune to St-Quentin)
Which School are you Currently Attending
*
Not Applicable - I am currently not attending school
Académie-Dalhousie
Aux Quatre Vents
Campbellton Learning Centre
Campbellton Middle School
College - Please specify
Dalhousie Learning Centre
Dalhousie Regional High School
École Marie Gaëtanne
Le Galion des Apalaches
Le Mosaique du Nord
Polyvalente Alexandre I. Savoie
Polyvalente-Roland Pépin
Sugarloaf Senior High school
University - Please specify
Submit
Youth in Action Centre
44 Salmon Boulevard│ Campbellton, NB │ E3N 3T7
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