Christmas Party for Home Care Workers

Name*

First NameLast Name

Date of birth (Month-Day-Year)*

Date

Date of your original entry to Canada (Month-Day-Year)*

Date

Country of origin

Last country of residence

Marital Status

Status in Canada*

Client ID number or UCI number, please refer to your work permit or PR card*

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Are you a home care worker?*

YesNoOther

Native Language

Please upload either your Work Permit or the front and back of your PR card.

CONFIDENTIALITY

All client information collected is confidential and securely stored, except when related to the harm of a minor. If your personal information needs to be shared for assistance purposes, your written approval will be requested beforehand. As a client, you have the right to refuse to answer any questions you find inappropriate. Statistical information is collected anonymously, except for the following required by Immigration, Refugees, and Citizenship Canada (IRCC) for newcomers with permanent resident status:

Your name
Contact information
Immigration client number and proof of your immigration status (original immigration papers must be presented for copying).

Our services are completely free, and we cannot accept any form of payment or gifts.

ACKNOWLEDGEMENT

I have read and accept the terms under which services will be provided. Please write your full name below:

Signature*