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Registration Form

Welcome! For this first step of the registration process, you have to fill out the fields of the form below. Please note that you must provide information for all the fields marked with a *.
First Name* :
Name* :
Gender* :
Date of birth* :    (eg. 01 / January / 1960)
E-mail* :
Address* :
City* :
Postal Code* :  (eg. A1A 1A1 in Canada or 99999 in the United States)
Province* :
Country* :
Telephone* : (Format : 000-000-0000)
Extension :
I am* :   of an organization which Assistance Program services are provided by Human Solutions. If you indicated “other” please briefly describe your status here .

I would like to be advised by email when new services / products become available on this site.

At least one of the two following fields must be filled out. Please, if ever your organization has provided you with an access code, make sure to use it below as it will speed up the registration process and ensure that you will be provided with all of the services you are entitled to.
Company / organization :
Access code :