Agencies - Dreams Take Flight

Agency Information
Agency Name*
Chapter Association*
Main Contact Name
First Last
Phone*
Website
Agency Address*
Street Address Address Line 2 City Province Postal Code
Qualifying Questions
As the Agency or Organization representative I have read and fully understand the criteria as noted on the previous page.*
As the Agency or Organization representative I fully understand that all nominated children for the flight will require a valid Canadian Long Form Birth Certificate.*
As the Agency or Organization representative I understand that any child put forth can not have a parent or legal guardian that works for Air Canada or another airline.*
As the Agency or Organization representative I understand that we will be required to participate in one of the local chapters fundraising events.*
Account Information
Name*
First Last
Email*
User Name*
Password*
Enter Password Confirm Password

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Email
This field is for validation purposes and should be left unchanged.

Agency Information