Salamander Fund (referred)

Identification of the person who referred you to the program

Full name•

Organization•

First name•

Last name•

Address•

Postal Code•

E-mail•

Phone number•

First name

Last name

Address (if different)

Postal Code

E-mail

Phone number

First and last name•

Address•

Postal Code•

Date of birth•

Acceptation - I acknowledge and certify that all the information and documents provided are true.

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Authorization - I authorize the Town of Brome Lake to contact my child's school and/or the person who referred me to the program.

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Save the information and complete the form later.