Family Services of the North Shore
Community Programs

REGISTRATION FORM
 

 GENERAL INFORMATION Date: September 24th, 2017

*
Last Name
(Parent):

*
First Name:

*Date of Birth:
/ /  *Gender:   F
*e-mail:

*Current Residence (Apt./Street):
  Willing to Receive Mail? Yes No  
City:
  Postal Code:   
 Please Indicate Municipality:   NV City    NV District    West Vancouver

*Phone No.:  *Message OK?  Yes No
 Cell No.:    Message OK?  Yes No

 PARTNER:


Name:

   
Gender:
M F
 
Date of Birth:

/ /
 
Relationship:


 CHILDREN:


*Name:

   
Gender:
M F
 
*Date of Birth:

/ /
 
Relationship:

  M F   / /  
  M F   / /  
  M F   / /  

 SERVICE:
  Mother Goose:  
  *Have you attended the Mother
  Goose program at FSNS before?
Yes No
*How did you find out about our programs?
 

Would you like information (by e-mail) about other FSNS Education programs and services?
Yes No

EMERGENCY HEALTH/CONTACT INFORMATION:
*Emergency Health Issues/Disabilities Needs:   Yes No  

*Emergency Contact Name:

*Phone No.:

If YES please explain:

 
DEMOGRAPHIC INFORMATION:
This information is optional, but it helps us report to our funders about who we are serving.

Racial/Ethnic Identity:   (Please note all information is reported anonymously.)


Primary Language (Language spoken at home):

English  

Farsi

  Korean   Cantonese   Mandarin   Spanish   Punjabi
Other (Please Specify):

Education Level:

Less than Grade 12  

H.S. Diploma

  Some Post Secondary   College Degree
University Degree   Post-Grad. Degree   Other      

Living Situation: Own Home  

Rent

  Other

Gross Annual Family Income:

Under 9,999  

10,000 – 14,999

  15,000 – 19,999   20,000 – 24,999   25,000 – 34,999
35,000 – 44,999   45,000 – 54,999   55,000 – 64,999   65,000 – 79,999   80,000 and over

Relationship Status:

Single  

Partnered

  Married   Separated   Divorced
FOR OFFICE USE ONLY CIMS Entry Complete (Date): Enrolled Date: End Date:

Thank you for yor time.
Family Services of the North Shore
Telephone: 604-988-5281 | Fax: 604-988-3961 | www.familyservices.bc.ca