Bundle of Support - Registration Form

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4. REGISTRATION FORM
   INSTRUCTIONS: Please provide your information in the fields below to register for our support group. This should be completed by the individual who is planning to attend the group. Please ensure that you include a response for all fields with an asterisk (*).

   INSTRUCTIONS: Please provide your information in the fields below to register for our support group. This should be completed by the individual who is planning to attend the group. Please ensure that you include a response for all fields with an asterisk (*).

6. CONTACT INFORMATION

8. First Name*

9. Last Name*

11. Phone Number*

    Please provide the best phone number that you can be reached at

12. Email Address*

    We will be sending an email with the instructions to join the virtual support group as well as different resources throughout our time together.

14. City or Town of Residence*

15. Postal Code*

17. Emergency Contact*

18. What is their relationship to you?*

20. Phone Number of Emergency Contact *

22. SCHEDULING AVAILABILITY
    INFORMATION: We will need to schedule an over-the-phone conversation with you in order to complete the intake process for our support group. We will be asking a series of questions, which should take anywhere from 15 minutes to 30 minutes in length.

    INFORMATION: We will need to schedule an over-the-phone conversation with you in order to complete the intake process for our support group. We will be asking a series of questions, which should take anywhere from 15 minutes to 30 minutes in length.

24. Please select the time(s) that you would be available for a phone call*

    Morning (9:00am - 11:30am) Afternoon (12:00pm - 4:30pm) Evening (4:30pm - 8:00pm)

    1. Monday morning
    2. Monday afternoon
    3. Tuesday morning
    4. Tuesday afternoon
    5. Wednesday morning

    1. Wednesday afternoon
    2. Wednesday evening
    3. Thursday morning
    4. Thursday afternoon
    5. Thursday evening
26. Scheduling Preference(s)

    Is there a specific time during the day that you would like us to call you? Please list the date and time in the field below (ex. Monday, May 3rd at 4:30pm)

30. FAMILY DEMOGRAPHICS
    WHY DO WE ASK FOR THIS INFORMATION? The demographic information collected in this section is used for reporting purposes only as required by our funder. Any question with an asterisk (*) is mandatory to complete, but those without can be skipped.

    WHY DO WE ASK FOR THIS INFORMATION? The demographic information collected in this section is used for reporting purposes only as required by our funder. Any question with an asterisk (*) is mandatory to complete, but those without can be skipped.

32. Were you born in Canada?*

    1. Yes
    2. No

33. If you were born in Canada, are you:

    1. Indigenous
    2. Francophone
    3. None of the above

34. If you were NOT born in Canada, have you lived here for less than 3 years?

    1. Yes
    2. No

35. If you have lived in Canada for less than 3 years, where did you live before moving here?

37. Total Number of Children (0-18 years of age)*

    Please tell us how many children that you care for.

38. Were your children:*

    1. Born in Canada
    2. Born outside of Canada
    3. Born in Canada and outside of Canaad

39. If born in Canada are your children or youth

    1. Indigenous
    2. Francophone
    3. None of the above

40. If not born in Canada, have any been here less than 3 years?

    1. Yes
    2. No

42. If applicable, how many have been in Canada less than 3 years?

43. Date of birth (1st child)*
    Date of birth (1st child)

44. Date of birth (2nd child)
    Date of birth (2nd child)

45. Date of birth (3rd child)
    Date of birth (3rd child)

47. Date of Birth (4th Child)
    Date of Birth (4th Child)

51. How did you learn about this workshop?*

    1. Facebook Page
    2. City Website
    3. Friend and family member
    4. I was referred or told by an agency or service provider
    5. Other

52. If you were referred by an agency or service provider, please provide their name

    E.g. Synergy, FCSS, Trellis, Healthy Families

54. Thank you for taking the time to complete this form. We look forward to connecting with you!

56. Freedom of Information & Privacy (FOIP)
    <i>Your personal information is being collected for activities related to the Parent & Caregiver Support Services (PCSS) program, workshop, seminar, and/or group activity and as such is deemed to be an activity of the City of Chestermere. The personal information is collected under the authority of Section 33(1)c of the Freedom of Information and Protection of Privacy Act, and will be used only for the purpose identified. If you have any questions or concerns about the collection or use of information you may contact the FOIP Coordinator at City Hall, 105 Marina Road, Chestermere, AB T1X 1V7, or call (403) 207-7050.

    Your personal information is being collected for activities related to the Parent & Caregiver Support Services (PCSS) program, workshop, seminar, and/or group activity and as such is deemed to be an activity of the City of Chestermere. The personal information is collected under the authority of Section 33(1)c of the Freedom of Information and Protection of Privacy Act, and will be used only for the purpose identified. If you have any questions or concerns about the collection or use of information you may contact the FOIP Coordinator at City Hall, 105 Marina Road, Chestermere, AB T1X 1V7, or call (403) 207-7050.

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Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit