YWCA JUMP Etobicoke-Registration Form

This form is private and confidential. The information provided will only be used by YWCA JUMP staff for reporting purposes to our funders.

If you need help filling out the form please ask for assistance: jumpetobicoke@ywcatoronto.org or 416.964.3883.

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* 1. Official Language of Preference

English

French

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* 2. First Name

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* 3. Last Name

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* 4. Phone

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* 5. Emergency contact

Emergency contact name and relationship to you.

Emergency contact phone.

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* 6. Email

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* 7. Gender

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* 8. Date of Birth

MM/DD/YYYY

Date

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* 9. Address

Street number and street name

Unit# (if applicable)

City

Postal Code

Province

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* 10. Immigration Status (YWCA JUMP is funded by Immigration, Refugees and Citizenship Canada (IRCC) and are required by the IRCC to confirm and request your proof of immigration status.)

Permanent Resident

Convention Refugee

Live-in Caregiver

Refugee Claimant

Citizen

Other (please be specify)

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* 11. Immigration Document Client ID Number or UCI number
(This includes your eight digit numeric Client ID number on your Permanent Resident Card; or on your Record of Landing/ IMM 1000 document; or on your IMM 5292 or IMM 5509 document; or your Temporary Resident Permit number; Ministerial Permit number)

I prefer to give my PR/UCI number over the phone

Not applicable for citizens

PR/UCI number

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* 12. How long have you been living in Canada?

Less than 1 year

1-4 years

More than 4 years

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* 13. Do you intend on becoming a Canadian Citizen

Yes

Unsure

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* 14. Country of Birth

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* 15. What Languages are you fluent in?

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* 16. Would you like to be on the YWCA JUMP Email list?

Yes

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* 17. The YWCA JUMP Program respects you and the information that you share with us. We are committed to protecting your personal information. All written information will only be seen by YWCA JUMP staff and our funder, Immigration, Refugees and Citizenship Canada (IRCC). You can ask to see your file and/or have a copy at anytime.

We will not share any of your personal information beyond the YWCA JUMP staff and our funder unless you agree and sign Consent to Release Information form, or in some special situations.

I confirm that I have read and understand how my personal information will be recorded and used by the YWCA JUMP staff and Immigration, Refugees and Citizenship Canada.

Yes

Other (please specify)

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50% of survey complete.