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Mothers Day Registration Form
1.
Please type your first name.
2.
Please type your last name.
3.
Which age group best describes you?
15-24
25-34
35-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95+
Prefer not to say
4.
Do you identify as:
Male
Female
Non-binary
Prefer not to answer
Other (please specify)
5.
What is your preferred language for the engagement session?
Hindi/Punjabi
English
Other (please specify)
6.
What is your ethnic or cultural origin background? Please choose all that apply.
Aboriginal (that is First Nations, Metis or Inuit)
White (e.g. European Descent)
South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.)
Chinese
Black (e.g. African or Caribbean)
Filipino
Latin American/Hispanic
Middle Eastern /Arabic
Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai, etc.)
West Asian (e.g., Iranian, Afghan, etc.)
Korean
Japanese
Prefer not to answer
Don't Know
Other (please specify)
7.
Please share your contact number.
8.
Please share your email address.
9.
Please share your house address.
10.
Please share your area postal code.
11.
Please select your neighborhood.
Cloverdale
Fleetwood
Guildford
Newton
South Surrey
Whalley
12.
Please share your current residency status.
Citizen
Permanent residents
Immigrants
Tourists
Other (please specify)