Hygiene Kit Registration Form
Through the support of the Government of Canada’s Emergency Community Support Fund, the Jean Augustine Centre will be providing a limited number of monthly hygiene kits to women or girls living in South Etobicoke whose households are experiencing financial challenges as a result of COVID-19 or other factors. Monthly registration by phone or email is required. Registration opens the first Monday of each month. One hygiene kit per household. All requests will remain private and confidential. Please fill in the form below.
Name of Parent/Guardian(if registrant is under 18):
Date of Birth (MM/DD/YYYY)
Phone Number (s):
Please select the month you are registering for:
Do you have one or two girls under the age of 18?
This information will be used to understand the demographics of those in need of the gift cards.
Under 18 years of age
$20,000/yr. - $30,000/yr.
$30,000/yr. - $40,000/yr.
Employment Status: Are you currently...
Employed Full Time
Employed Part Time
Unemployed and receiving Ontario Works
Unemployed and receiving Ontario Disability Support Program
Household Composition: Including yourself how many people are living in your household?
5 or more
Household Composition: How many of your household members are below the age of 18?
4 or more
I confirm that I am a resident of South Etobicoke.
I confirm that my household is experiencing financial challenges as a result of COVID-19 or other factors.
I understand that the kit should not be obtained for members outside of my household.
I acknowledge that the above information is complete and accurate to the best of my knowledge.
I acknowledge that this application form is for women and/or girls.
I have read and understand the information presented. I agree to cooperate with all Jean Augustine Centre procedures and regulations.
Should be Empty: