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
If other
OHIP # & Version
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Primary Phone #
Alternative Phone #
Email address
Preferred method of contact*
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
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?
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)?
In general, what would you say your overall physical health is?
In general, what would you say your overall mental health is?
Which priority populations best describes you? (choose one)
- Aboriginal
- Age Group - Senior
- Age Group - Youth
- Poverty / Low income
- Racialized
- Rural

Welcome to all participants of the Community Health Centre’s programs!