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Program Registration Online Form
Welcome to all participants of the Community Health Centre’s programs!
We ask that you please complete the following registration form. The data is required for reporting to the Ministry of Health and we ask personal socio-demographic questions because we care about your needs and want to find out who we serve. **All information is kept private and is used to plan services according to your needs!**
Name of Program
Name
*
First
Last
Preferred Name
Preferred Pronoun
he/him/his/himself
she/her/hers/herself
they/them/their/theirs/themselves
Other
If other
OHIP # & Version
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Primary Phone #
Alternative Phone #
Email address
Preferred method of contact
*
Phone
Email
Emergency Contact
Emergency Contact Phone #
Are there any medical conditions or allergies (e.g. bee sting) we should be aware of?
Diabetes
Heart Disease (Heart Attack, Angina)
High Blood Pressure
Osteoporosis
Disability
Asthma or Lung Disease
Seizures / Epilepsy / Convulsions
Fibromyalgia
Memory Difficulty
COPD
Body Temperature Regulation
Other
Examples of Medical Conditions: (Please check off any that apply)
If other please specify the medical condition
I agree / Consent
*
I hereby release the NLCHC for all damages, claims, and demands arising because of participation in the program. I am providing accurate information to the best of my knowledge. I understand that any personal information shared during the program is confidential and I will not share it with others outside this program.
Date of consent
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
I agree / Consent
agree to allow the NLCHC to photograph and/or video me (and my children) during my involvement in the NLCHC programs. I give consent for the NLCHC to use this photo and/or video in all media (i.e. website, video slide shows, face book, you tube, etc.) or to share it with third party organizations, (i.e. funders, community partners, LHIN, etc.) to describe and promote the NLCHC’s work in the community.
Consent
Please do not use my photograph
Which language are you most comfortable speaking?
English
French
Other
If other please specify language
Which gender best describes you?
Female
Male
Intersex
Trans - Female to Male
Trans - Female to Female
Two - Spirit
Do not Know
Prefer not to answer
Other
If other please specify the gender.
Which sexual orientation best describes you?
Bisexual
Gay
Heterosexual
Lesbian
Queer
Two - Spirit
Do not know
Prefer not to answer
Other
If other please specify sexual orientation
What is the highest level of formal education you have completed?
To young for primary completion
Primary - any grade from 1 to 8
Secondary or Equivalent - any number of years
College or Equivalent
University Bachelor's
University Post - Graduate
Do not know
No formal education
Prefer not to be answer
Other
If other please specify you highest level of formal education completed
Approximately how much is the yearly income received by everyone in your household?
$0 - $14,999
$15,000 - $19,999
$20,000 - $24,999
$25,000 - $29,999
$30,000 - $34,999
$35,000 - $39,999
$40,000 - $59,999
$60,000 - $89,000
$90,000 - $119,000
$120,000 - $149,000
Over $150,000
Do not know
I prefer not to answer
How many people are supported by this income?
Which of these options best describe the people who live in your household?
Couple with child(ren)
Couple without children
Sibling(s) (brother/sister)
Grand Parent with grandchild(ren)
Single Parent
Unrelated Housemates
Extended Family
Live alone
I prefer not to answer
Other
If other please specify the household composition
Which racial or ethnic group best describes you?
Asian - East
Asian - South
Asian - South East
Black - Caribbean
Black - African
Black - North American
First Nation
Indian - Caribbean
Indigenous/Aboriginal
Inuit
Latin American
Metis
Middle Eastern
White - European
White - North American
Mixed Heritage(please specify)
Do not know
Prefer not to answer
Other
If Mixed Heritage please specify
If other please specify your ethnicity
Where were, you born?
If born outside of Canada, in what year did you arrive in Canada?
Date Format: MM slash DD slash YYYY
Do you have any of the following? Check ALL that apply.
Chronic illness
Developmental disability
Drug or alcohol dependence
Learning disability
Mental illness
Physical disability
Sensor disability
Prefer not to answer
None
Do not know
How would you describe your sense of belonging to your community? (Sense of belonging is feeling like you are part of something, connected and accepted)?
Very strong
Some what strong
Some what weak
Very weak
In general, what would you say your overall physical health is?
Excellent
Very Good
Good
Fair
Poor
In general, what would you say your overall mental health is?
Excellent
Very Good
Good
Fair
Poor
Which priority populations best describes you? (choose one)
Aboriginal
Age Group - Senior
Age Group - Youth
Poverty / Low income
Racialized
Rural
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