Intake Form

Service Area*
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The following fields are all hidden by default and show conditionally based on the service area.
Children & Youth Programs:
LIFE*SPIN is partnering with Ashley Homestore to provide our families with Beds this Christmas. Families who qualify will recieve a twin bed frame, mattress, pillow, coverlet, and sheet set. Ashley Homestore will ship the bed directly to the family in need and have it set up for them.

This program is for children ages 3 to 16 who are currently without a bed. The family needs to be surviving on low-income or transitioning out of a shelter. You can learn more about the program at: https://ashleyhomestore.ca/pages/hope-to-dream

If you qualify, LIFE*SPIN will send your family's information to Ashely Homestore. From there Ashley Homestore will be contacting families to set up delivery. Delivery will be expected in December.

Please fill out the form below with the nessary informaiton. We will contact you to let you know the status of your application.

Please note that this program is only available to current LIFE*SPIN clients.

If you are in need of multiple beds you will have to fill out a form for each child.
I consent to having my information sent to Ashley Homestore
Nutrition Program*
How did you learn about LIFE*SPIN's Program?
Name of the Child Receiving the Bed *
Age of Child Receiving the Bed*
Social Assistance (Ontario Works, Internal Reviews, Special Diet Allowance)Discretionary Assistance (funerals, pregnancy, utilities, diabetic supplies, mattresses , etc)Seniors Pensions (Canada Pension Plan, Guaranteed Income Supplement, Old Age Security, Seniors Dental Program, Seniors Co-Payment Program)Disability Benefits (Special Services at Home [children only], Canada Pension Plan-Disability, Ontario Disability Support Program, Assistance for Children with Severe Disabilities, Disability Tax Credit)Health Benefits (Ontario Drug Benefit, Vision & Dental Benefits, Canadian Dental Care Plan, Trillium Drug Program)Housing Supports Forms (Housing Stability Bank, Connected for Success, Subsidized Housing, Ontario Renovates, Ontario Electricity Support Program)Death Benefits (Canada Pension Plan - Spouse & Child Survivor Benefits, Canada Pension Plan - Death Benefit, Discretionary Funeral Assistance)
Advocacy Short
Event/Workshop Info:
Tax Years
Please list the tax year(s) you would like help filing.
🌱Seed Planting Party
Come join us on April 24 from 1PM to 3PM for our Seed Planting Party. We’ll have fun activities, and you can get your hands dirty planting seedlings for our Pocket-Sized Farms Program.

This event is for Children of all ages! Each child will have the opportunity to start some of their own seedlings to bring home.

When: Friday, April 24, from 1PM to 3PM

Time: 1:00PM to 3:00PM

Location: LIFE*SPIN Office, 866 Dundas Street, London, ON

If you are driving you can park at the Western Fair Market. LTC Bus routes 2 and 20 also stop near the LIFE*SPIN Office.
In the box below please provide the name and ages of the children who will be attending Seed Planting Party:*
🍅Pocket Sized Farms 2026
Child's First Name*
Child's Last Name*
Age of Child*
Child Information
Please provide any additional information you would like us to know about you child, such as dietary restrictions and accommodations.
In containersIn the groundBoth in containers and in the ground
YesNoI would like more information
Not sure what double digging is? Click Here to learn more about starting your garden and preparing your soil.
Ed Blake ParkThames ParkBothI will not be attending
YesNoI would like more information
YesNoI would like more information
Contact Information
Please provide the participant's Parent/Guardian information in the section below. We will be delivering gardening kits, so please ensure that the contact information and address sections are correct.
fromEmail
First Name*
Last Name*
Please input the names of all the individuals in your family who will need to shop at the Free Store.
Date of Birth*

DayMonthYear
Email is {email36}*
Email*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number. Do not include a preceding 1, even if your number is long distance.Format: (000) 000-0000.
Yes
Name and phone number (including extension) of alternate contact:
Address*

Street Address

Unit Number

CityProvince

Postal Code
City*
City
Province*
Province
Postal Code*
Postal Code
Buzzer Number
If you live in an apartment building, enter the buzzer number
Please double check this address information, including the unit number. If the address is incorrect you may not receive the service you have requested.
Household Information

The mission of LIFE*SPIN is to provide information and support for individuals who are surviving on low incomes
SingleCouple
Your partner's first & last name
EnglishArabicSpanishOther
YesNo
Please note that we currently only have an interpreter for Arabic, Greek, and Spanish. If you speak any other language you will have to provide your own intperpreter.
Canada Child Benefit (CCB)Ontario Disability Support Program (ODSP)Life Stabilization - Ontario Works (OW)Old Age Security (OAS)Guaranteed Income Supplement (GIS) - FederalGuaranteed Annual Income System (GAINS) - ProvincialRetirement Income Fund (RIF)Canada Pension Plan (CPP) RetirementWork Pension (WP)Canada Pension Plan Disability (CPP-D)Assistance for Children with Severe Disabilities (ACSD)Student Loan (S-Loan)Child Support (C-Sup)Spousal Support (S-Sup)Employed (EMP)Self- Employed - ie Uber, Rental Income, Contract, etc (S-EMP)Employment Insurance (El)Workers Compensation Benefits (WSIB)Other
Income Sources
How many adults (18+) live in your household?

Please enter the number of people who live in your household, by age category:*

Rows	Male	Female	Non-Binary
Age 0-6
Age 7-12
Age 13-18
Age 19-25
Age 26-64
Age 65+

YesNo
If yes, date the baby is due.

MonthDayYear
Children Ages 0-12
Tables Field
Youth Ages 13 - 25
Tables Field
Adults Ages 26 - 64
Seniors 65+
Tables Field
Children 7-12
Tables Field
Girls Ages 13-18
Tables Field
Children 18 and under
Tables Field
How many of these adults are 60+?
How many children live with you (less than 18 years old)?
Child Information*
Today

MonthDayYear
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Should be Empty:

The following fields are all hidden by default and show conditionally based on the service area.

🌱Seed Planting Party

🍅Pocket Sized Farms 2026

Contact Information

Please provide the participant's Parent/Guardian information in the section below. We will be delivering gardening kits, so please ensure that the contact information and address sections are correct.

Household Information