Environmental Sensitivities
Voluntary Registration Form

Please complete this registration form and return it to the City of Ottawa by:

FAX: 613-580-9648, or by

MAIL to:

West Nile Virus Environmental Sensitivities Voluntary Registry

Ottawa Public Health

8th floor, East Side Duty Desk

100 Constellation Crescent

Ottawa, ON K2G 6G8

Full Name:
Municipal Street Address: (e.g. 5473 Lion'sHead Rd. Apt. 3)
City:
Postal Code:
Telephone(s):	Home:	Work:
Email address: (if applicable)

I wish to place my name on the Public Health's Environmental Sensitivities Voluntary Registry and understand that this information will be kept privileged and confidential.

_____________________________________________	_________________
Registrant's Signature	Date

Thank You