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SWITCH REGISTRATION FORM
YOUR INFORMATION:
First Name:
*
Last Name:
*
Phone Number:
*
Email Address:
*
Student Number:
*
NOTE - SWITCH is only open to St. Clair Students at the Chatham Campus.
Tell us a bit more about you (optional):
Gender:
Male
Female
Other
Age:
Under 20
20-29
30-39
40+
Do you smoke?:
Yes
No
Trying to Quit
Just Quit
How would you rate your stress level?:
Scale - 1 - No Stress, 5 - Everyday stress, 10 - Super stressed
1
2
3
4
5
6
7
8
9
10
Note:
Once your information has been submitted you will be contacted by the HealthPlex with more information.