| If you are interested in becoming a member of the RockHaven team, please complete this form and we will contact you at our earliest conveniences. |

| 308 Front Street North, Box #190 Campbellford, Ontario K0L 1L0 |
| Phone #: 705-632-0255 Fax #: 705-632-0259 |

| RockHaven Children's Services Inc. |
