Guest Registration

PERSONAL INFORMATION Last Name First Name Initial Date of Birth MM/DD/YYYY Gender MaleFemale Ethnic origin Status nativeNon-status nativeMetisInuitAsianBlackCaucasianLatin - HispanicMiddle EasternMixedOther RESIDENCY INFORMATION Current housing Family house or apartmentOwn house or apartmentRent house or apartmentHomeless passing throughHostelRooming houseHotelHospital psychiatricHospital medicalGateway Street Address City Province / Postal code / Phone number Previous city

EMERGENCY CONTACTS Name Phone Relationship Address

REGISTRATION Registered MM/DD/YYYY Barred until

HEALTH

Describe any of the following health conditions:
Physical disability		Substance abuse/Addiction
Mental illness		Allergies
Are you being treated for any of the following? (Check all that apply)
HIV	Hepatitis A	Diabetes
TB	Hepatitis B	Asthma
Seizures	Hepatitis C

EMPLOYMENT

Education
Occupation
Work Experience

INCOME SOURCES

Employment-full time	Income assistance IS	Disability benefits -Level 1
Employment-part time	Income assistance AISH	Disability benefits -Level 2
Employment casual	Income assistance SFB	No source of income
Pension(s)

COMMUNITY RESOURCES

INTERESTS

Recovery Program	Employment Skills Training	Sewing Crafts
Computer Literacy Program	Spiritual Care	Looking For Apartment

Goals, dream, job, how can the Mission help you?