Thank You – Social Shuffle

Thank you for joining our inaugural Social Shuffle Event! Please take a moment to fill out the form below, which will help us facilitate your experience and connect you with other participants.

If you have any questions or concerns please contact us at feeforservice@empowersimcoe.ca.

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Participant Information

Participant's Name *

First

Last

What are the participants goals/desired outcomes from participating in this program? *

• To meet a new friend
• Practice starting/maintaining conversations
• Find a romantic relationship
• Build Confidence
• Other (add your own)

Select all that apply

Other goals/outcomes:

After the Social Shuffle event, how would the participant prefer to be contacted by mutual matches? *

• Phone – Voice Call
• Phone – Text/SMS
• Email
• Social Media
• Other (add your own)

Select all that apply

Other methods of contact:

Parent/Guardian Information

Parent/Guardian Name(s) *

Parent/Guardian Email *

Home Phone

Cell Phone

Work Phone

DISCLAIMER AND ACKNOWLEDGEMENT REQUIREMENT

Disclaimer

• I understand that any connections made outside of the official Social Shuffle event are not monitored or facilitated by Empower Simcoe.

Acknowledgement

• I acknowledge that I will be interacting with other participants independently during the Social Shuffle event, unless support staff is required.

Name of person completing form: *

Relationship to participant: *

Signature

Clear Signature

Thank You!

Click the ‘Submit’ button below to complete your registration.

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