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English (Canada)
English (Canada) Français du Canada

Intake Request Form

Your Personal Details

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Current Residential Address

Immigration Related Information

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This can be a Confirmation of Permanent Residence, a Work Permit, a Refugee Claimant document, a Permanent Resident Card, etc.

If uploading a Permanent Resident Card or other two-sided document, please ensure both sides are attached.
Drop files here or
Accepted file types: pdf, docx, doc, jpg, gif, tiff, Max. file size: 10 MB, Max. files: 1.

    Emergency Contact Information

    Services

    Details of Family Members

    Would you like to register your family members so that they can also receive services with us?

    Member 1

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    Member 2

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    Member 3

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    Member 4

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    Member 5

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    Member 6

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    Consents and Confidentiality Statement

    Mail Consent

    I consent to your organization collecting, storing, and using my personal information for the purposes of providing services and communications related to events, workshops, and other relevant activities. I understand that appropriate security measures will be in place to protect my data from unauthorized access or misuse.

    I consent to the sharing of my personal information with trusted third-party partners of your organization solely for the purpose of delivering services and communications as described. I am aware that I have the right to withdraw my consent at any time, which may impact the services provided to me.

    Clear Signature
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    DD slash MM slash YYYY
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    99 Christie Lake Road, Perth, Ontario, K7H 3C6 Canada

    (343)-402-8630 |

    settlement@lanarkcounty.ca

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    CARMIS (Case Management Solution for Non-Profits)