PEI Public Library’s Music and Memory Program

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Personal information on this form is collected under Section 31(c) of the Freedom of Information and Protection of Privacy Act and will be only for the purpose of providing library services. Questions regarding the collection and use of this information can be directed to the Director of Libraries & Archives at P.O. Box 2000 Charlottetown, PE C1A 7N8.

Identification
Enter information for the participant who will be recieving the device.
For example: C1B 0X1 or 12345
For example 902-555-5555
Caregiver/Designate Information
For example 902-555-5555