La Relance

Program Registration Form

La Relance will respond to your registration request within two business days. The information you provide on this form will help us determine the best programs and services for you.

All personal information will be kept strictly confidential.

Required fields are marked with an asterisk.

 

Language

Age

Residency status

Educational level

Current employment situation

Check all that apply.

Functional limitations (disabilities) (if applicable)

Source of income

I’d like more information about the following programs or services