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Adult Learner Intake Form
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Email
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Your email
Name
*
Your answer
Phone number (please verify if cell)
*
Your answer
Gender: How do you identify?
*
Female
Male
Non-binary
Other:
Do you wish to identify as First Nations in Canada?
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Yes
No
Please select the option that BEST applies to you.
*
Canadian citizen
Permanent resident
Temporary resident
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Other:
Age
*
0 - 17
18 - 34
35 - 54
55+
Education
*
None
Grade 1 - 6
Grade 7 - 9
Some High School
High School Graduate
Some Post-Secondary
Post-Secondary Graduate
Special Education
Other:
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How did you find out about our services?
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Word of Mouth
Newspaper
Our Web Site
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Other:
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Have you been referred by an Agency or Organization? If yes, please provide name.
Your answer
Do you have any Medical Issues (epilepsy, diabetes, etc.) that we should be aware of? If Yes, please specify:
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