EmailMe Form - The Village VIP Registration Form

Full Name: *

First Last

Preferred name on name tag: *

Date of Birth: *

MM / DD / YYYY

What is your gender? *

Male

Female

Other

Prefer not to answer

Email:

Phone

### - ### - ####

Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

In case of emergency, who can we contact on your behalf?

Emergency contact name:

First Last

Emergency contact phone number:

### - ### - ####

*Please Note: It is important that we gather data to make improvements to our programs and support future initiatives. Some of the questions are specifically asked so that we can promote inclusive and accessible practices. Your confidentiality will be assured. Your personal or identifiable information is never shared. Your responses are combined with other responses and are summarized in a report that is shared with the government of Canada and our partners to track the performance of the project and to help inform trends for improvement.

Do you live alone? (30% of seniors live alone in Ontario):

Yes

No

What is your first language?

English

French

Other

Do you identity as Indigenous?

Yes

No

Prefer not to answer

Do you identity as Francophone?

Yes

No

Prefer not to answer

Do you identity as a newcomer to Canada?

Yes

No

Prefer not to answer

Do you have access to the internet at home?

Yes

No

Do you have access to a device? (cell phone, tablet, computer):

Yes

No

If yes, what type of device do you have?

Do you have access to safe transportation to attend our programming?

Yes

No

Do you have access to safe transportation to attend other community activities/services?

Yes

No

If no, can we support you in accessing transportation supports?

Yes

No

Unsure

How did you hear about The Village?

Social media (Facebook, Instagram, other)

From a friend or family member

Email from The Village at Canadore College

Other

If you were referred by an agency, please specify the agency: