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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
(Required)
First
Last
Preferred Name
OHIP # & Version
Preferred Pronoun
he/him/his/himself
she/her/hers/herself
they/them/their/theirs/themselves
Other
If other
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Date of Birth
(Required)
Month
Day
Year
Primary Phone #
Alternative Phone #
Email address
Preferred method of contact
(Required)
Phone
Email
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
(Required)
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
Month
Day
Year
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
What is your mother tongue?
English
French
Other
If other please specify language
If your mother tongue is neither French nor English, in which of Canada’s official languages are you more comfortable?
English
French
Do you require language interpretation?
Yes
No
What language do you feel most comfortable speaking in with your provider?
English
French
Albanian
Amharic
Arabic
ASL (American Sign Language)
Bengali
Bulgarian
Burmese
Georgian
Greek
Cantonese
Czech
Dari
Farsi
Gujarati
Hausa
Hebrew
Hindi
Hungarian
Italian
Karen
Korean
Mandarin
Nepali
Pashto
Polish
Portuguese
Punjabi
Rohingya
Romanian
Russian
Serbian
Slovak
Somali
Spanish
Swahili
Turkish
Twi
Ukrainian
Tagalog
Tamil
Thai
Tibetan
Tigrinya
Taishanese/Toishanese
Urdu
Vietnamese
Do not know
Prefer not to answer
Other
Another Language (please specify)
Were you born in Canada?
Yes
No
Do Not Know
Prefer Not to Answer
If NO, what year did you arrive in Canada?
What country were you born?
Do you identify as First Nations, Métis and/or Inuk/Inuit?
Yes, First Nations
No
Yes, Inuk/Inuit
Yes, Métis
Do not know
Prefer not to answer
This question is about how you identify yourself (e.g. includes status or non-status)
What is your ethnic or cultural background?
For example: Canadian, Chinese, East Indian, English, Filipino, French, German, Irish, Italian, Jamaican, Jewish, Polish, Portuguese, Scottish, etc.
Which of the following best describes your racial group?
Not Applicable (e.g., Identified as Indigenous in previous question)
White (e.g., European descent)
Latin American (Hispanic or Latin American descent)
South Asian (e.g., Bangladeshi, Indian, Indo-Caribbean, Pakistani, Sri Lankan, etc.)
Southeast Asian (e.g., Filipino, Vietnamese, Cambodian, Thai, Indonesian, etc.)
Middle Eastern, Arab or West Asian (e.g., Afghan, Egyptian, Iranian, Lebanese, Persian, Turkish, Kurdish, etc.)
Black (e.g., African, Afro-Canadian, Afro-Caribbean, Afro-Egyptian etc.)
East Asian (e.g., Chinese, Korean, Japanese, Taiwanese, etc.)
Do not know
Prefer not to answer
Another race/ethnic group (Please specify)
If another please specify
Do you identify as a person with a disability?
Yes
No
Do Not Know
Prefer not to answer
Other
If you wish, please specify here
Could you benefit from support related to any of the following?
Alzheimer’s Disease/Dementia
Autism Spectrum Disorder
Chronic Illness (e.g. sickle cell, diabetes etc.)
Cognitive Disability
Developmental Disability
Drug or Alcohol Dependence
Learning Disability
Mental Illness
Sensory Disability (e.g., low vision, blindness, deafness, hard of hearing etc.)
Physical Disability
None
Do not know
Prefer not to answer
Other
If other please specify
What is your sex assigned at birth? (Select only ONE)
Female
Male
Intersex
Do Not Know
Prefer not to answer
What is your current gender identity?
Woman
Man
Genderfluid or genderqueer
Questioning or unsure
Two-Spirit
Nonbinary
Do not know
Prefer not to answer
Another gender identity
If another gender identity Please specify
Do you identify as transgender?
Yes
No
Do Not Know
Prefer not to answer
Transgender is an umbrella term used to describe people whose gender identity or gender expression differs from the sex they were assigned at birth.
Which category best describe your sexual orientation?
Asexual
Bisexual
Demisexual
Gay
Lesbian
Pansexual
Queer
Questioning or unsure
Same gender loving
Two-spirit
Straight/Heterosexual (male/female relationships)
Do not know
Prefer not to answer
Another sexual orientation
If another sexual orientation please specify
Do you currently have difficulty paying for basic needs?
Yes
No
Do not know
Prefer not to answer
Not applicable, I do not have to pay for basic needs
What was your total family income before taxes last year
$0 - $19,999
$20,000 - $ 39,999
$40,000 - $59,999
$60,000 - $79,999
$80,000 - $119,999
$120,000 - $149,999
$150,000 or more
Do not know
Prefer not to answer
How many people does this income support?
More than one
Do not know
Prefer not to answer
Include yourself + any dependents such as parents, children, etc.
If yes please specify how many
How would you describe your sense of belonging to your community? Would you say it is:
Very Week
Somewhat Week
Somewhat Strong
Very Strong
Do not know
Prefer not to answer
(Sense of belonging is feeling like you are part of something, connected and accepted)
In general, would you say your overall physical health is?
Poor
Fair
Good
Very Good
Excellent
Do not know
Prefer not to answer
In general, would you say your overall mental health is?
Poor
Fair
Good
Very Good
Excellent
Do not know
Prefer not to answer
What is your current level of education?
No formal schooling
Grade school (grade 1-8)
Some high school, but did not graduate
High school or high school equivalency certificate (grade 9-12)
Completed Registered Apprenticeship or other trades certificate or diploma (or ongoing)
College, CEGEP or other non-university certificate or diploma (or ongoing)
Undergraduate degree or some university
Postgraduate degree or professional designation (e.g., Master’s, PhD, MD)
Do not know
Prefer not to answer
What is your current housing situation?
A place you or your family owns
A place you or your family rents
Correctional facility
Long -term care facility
Supportive housing or Group Home
Staying in someone else’s place because you have no alternative
Experiencing homelessness (e.g., shelter, living in a public place or vehicle)
Social housing, Subsidized housing or Rent -geared -to –income
Do not know
Prefer not to answer
Other
If other please specify
Who do you live with? (Check ALL that apply)
Parent(s) or Guardian(s)
Spouse or Partner
Child(ren)
Grandparent(s)
Sibling(s)
Other family
Friends or Roommates
Paid caregiver or attendant
Alone
Do not know
Prefer not to answer
Other
if other please specify
Email
This field is for validation purposes and should be left unchanged.
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