Membership Form 2020 – 2021

MEMBER:

NewFamilyRenewalSupport

FOR NEW MEMBERS - How did you hear about us?

PARENT (MEMBER) MotherFatherOther

LAST NAME:

FIRST NAME:

DATE OF BIRTH:

HOME PHONE NUMBER:

CELL PHONE NUMBER:

EMAIL ADDRESS:

COMPLETE ADDRESS:

SPOKEN LANGUAGE(S):

FrenchEnglish

FAMILY TYPE:

Single ParentBoth Parents

EMPLOYMENT:

Mother: YesNo
Father: YesNo

EMPLOYER(S):

COUNTRY OF ORIGIN (other than Canada):

DATE OF ARRIVAL IN CANADA:

WHICH PROGRAMS WILL YOU USE THIS YEAR?

Individual SupportDiscussion groups between parentsInformation sessionsRespite (0-30 years old)Help finding babysittersIncontinence products (other than babies)

THIS YEAR I WANT TO BE INVOLVED IN:

Helping other parentsBoard of directorsAdvocacy for persons with disabilitiesFundraising committee

Other (specify):

CHILD / YOUNG ADULT - 1:

Sex: MaleFemale

LAST NAME:

FIRST NAME:

DATE OF BIRTH:

CHILD ATTENDING SCHOOL IN 2020-2021? YesNo

NAME OF INSTITUTION:

YOUR CHILD / YOUNG ADULT LIVES: With Both ParentsWith MotherWith FatherShared CustodyIn Housing ResourceOther

PRINCIPAL DIAGNOSTIC (check only one box):

Multiple disabilitiesMultiple disabilities (with profound intellectual disability)Global developmental delaySpectrum disorder autismIntellectual disabilitySensory impairmentPhysical disability

CHILD / YOUNG ADULT - 2:

Sex: MaleFemale

LAST NAME:

FIRST NAME:

DATE OF BIRTH:

CHILD ATTENDING SCHOOL IN 2020-2021? YesNo

NAME OF INSTITUTION:

YOUR CHILD / YOUNG ADULT LIVES: With Both ParentsWith MotherWith FatherShared CustodyIn Housing ResourceOther

PRINCIPAL DIAGNOSTIC (check only one box):

Multiple disabilitiesMultiple disabilities (with profound intellectual disability)Global developmental delaySpectrum disorder autismIntellectual disabilitySensory impairmentPhysical disability

IMPORTANT NOTICE

To enable Solidarité de Parents de Personnes Handicapées to pursue its mission and to comply with the "Law on the Protection of Personal Information in the Private Sector," we urge you to answer the following questions, sign this form and return it to Solidarité de Parents de Personnes Handicapées (address overleaf).

In addition, in order to avoid significant costs to the organization, e-mail will be the preferred means of communication.

Thank you for your cooperation

AUTHORIZATION REQUEST FOR TAKING PICTURES AT DIFFERENT EVENTS

I authorize the association to take pictures at various events (AGA, association’s activities) and to use them appropriately (website, Facebook, annual report, etc.).

YesNo