Confidential Profile – HOL Workshop To download and fill in the form manually, click here. ================================================================ You may alternately fill out the form below and it will be submitted once you have completed it. Confidential Profile for HOL Workshop Instructions - Please answer all of the questions. Indicate N/A where applicable. Please return to Roland Bérard by mail or email.Name* Name Last Name Gendre* M F Adresse* Address Address line 1 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code TEL*Email* Email Confirm email Occupation*Medication - Please list the medication that you are currently taking or that you have taken in the past 2 years. Please indicate the condition for which this medication was prescribed.*State your current physical and medical condition*Have you ever been hospitalized or treated for psychological difficulties? Has psychological treatement ever been recommended to you? If yes, what was the reason and please indicate the date and year.*Signature of participantDate*Name in capital letters*Age*CAPTCHA