Family Services of the North Shore
Community Programs

REGISTRATION FORM
 

 GENERAL INFORMATION Date: September 20th, 2018

*
Last Name
(Parent):

Preferred Name:


*
First Name:


*Date of Birth:
/ /  *Gender:

*Current Residence (Apt./Street):
  Willing to Receive Mail? Yes No  
City:
  Postal Code:   
 Please Indicate Municipality:   CNV    DNV    Maplewood    DWV    Other

*Phone No.:  *Message OK?  Yes No
 Cell No.:    Message OK?  Yes No
*E-mail:    Message OK?  Yes No

 PARTNER:


Name:

   
Gender:
 
Date of Birth:

/ /
 
Relationship to child:


 CHILDREN:


*Name:

   
Gender:
 
*Date of Birth:

/ /
 
Relationship:

    / /  
    / /  
    / /  

 SERVICE:
Parent Child Mother Goose – Which location would you prefer?:
North Vancouver City Library
i hope family centre - Maplewood
West Vancouver Memorial Library
  *Have you attended the Parent Child Mother Goose program at FSNS before?
Yes No
*How did you hear about the programs?
 

Would you like information about other FSNS Education programs and services?
E-Mail Yes No

Postal Yes No

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

*Emergency Contact Name:

*Emergency Contact 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.)


New to Canada? Yes No What year did you immigrate/arrive?


Primary Language (Language spoken at home):

English  

French

 

Farsi

  Korean   Cantonese   Mandarin   Spanish   Punjabi
Other (Please Specify):

Gross Annual Family Income:

Under 9,999  

10,000 – 14,999

  15,000 – 19,999   20,000 – 24,999   25,000 – 29,999
30,000 – 34,999   35,000 – 40,999   40,000 – 44,999   45,000 – 49,999   50,000 – 54,999
55,000 – 59,999   60,000 – 64,999   65,000 – 69,999   70,000 – 74,999   75,000 – 79,999
80,000 and over   Undisclosed      

Relationship Status:

Single  

Partnered

  Married   Separated   Divorced   Widowed
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