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YWCA JUMP Etobicoke- Registration Form

This form is private and confidential and will only be used by YWCA staff and our funder, Immigration, Refugees and Citizenship Canada (IRCC). It is designed to help us identify your settlement/employment needs. For more information please read the IRCC "Gathering Information" Document. >>>here<<< .

Official Language of Preference

English      French      Unknown/No Preference

Please note that we are currently unable to provide services in French. However, we are happy to refer you to another agency. For more information or services in French, please visit the IRCC website at: Click Here .

First Name

Last Name

Email

Phone Number  -  -

Do you consent to receive SMS text reminders for the workshops you register for at JUMP Etobicoke?

Yes      No

Emergency Contact / Relation to you

Emergency Contact Number

I identify as: Male    Female    Transgender    Gender Diverse    Prefer Not to Disclose

Date of Birth

Street Number and Street Name   Unit

City Not SelectedAgincourtAjaxAncasterAtikokanAuroraBarrieBordenBowmanvilleBracebridgeBradfordBramptonBrantfordBrooklynBurlingtonBurns LakeCalgaryCambridge BayChathamConcordCourticeCutlerDon MillsDownsviewDrydenDuncanEast YorkEdmontonEganvilleElginetobicoEtobicokeFort FrancesFort HopeFort St. JamesFort WilliamGeraltonGillamGoderichGuelphHalifaxHamiltonHarrowHighland CreekHumboldtKeswickKettle &amp; Stoney Point First NationKingstonKitchenerListugujLondonMaltonManiwakiMapleMarkhamMarmoraMillbrookMiltonMississaugaMonctonMontrealMoose FactoryMoosoneeMorningsideNanaimoNeskantagaNew LiskerdNewmarketNiagara FallsNo City IndicatedNorth YorkOakvilleOhswekenOrangevilleOshawaOttawaParisParry SoundPembrokePeterboroughPickeringPortage LaPrairieReginaRichmond HillSalmon ArmSarniaSaskatoonSault Ste. MarieScarboroughSelkirkSioux LookoutSt. CatherinesStoufvilleSturgeon FallsSudburySurreyThe PasThompsonThorn HillThorncliffeThunder BayTimminsTorontoTrentonVancouverVaughanVictoriaWalpoleWasaga BeachWaterlooWellandWest HillWestonWhitbyWillowdaleWinnipegWoodbridgeWoodstockYorkYork Landing

Postal Code

Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Status in Canada

Permanent Resident Convention Refugee Live in Care Giver Gaza Temporary Resident Visa CUAET Temporary Resident Visa Refugee Claimant Canadian Citizen Other

Immigration Document Client ID Number or UCI number: (This includes your eight or eleven digit numeric Client ID number on your Permanent Resident Card; or on your Record of Landing/ IMM 1000 document; or on your IMM 5292 or IMM 5509 document; or your Temporary Resident Permit number; Ministerial Permit number)

I prefer to give my PR/UCI number over the phone Not applicable for citizens

Immigration Document Client ID Number

Date of Landing

Do you intend to become a Canadian citizen?

Yes No Unknown/Not sure

Place of Birth (Country)

Not SelectedAfghanistanAkrotiriAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAshmore and Cartier IslandsAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBassas da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCoral Sea IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDhekeliaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambia, TheGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJan MayenJapanJerseyJordanJuan de Nova IslandKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontserratMoroccoMozambiqueNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSpratly IslandsSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin IslandsWake IslandWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabwe

What racial or ethnic group(s) do you identify with?

Arab, Middle Eastern or West Asian Black East Asian Indigenous Latin American South Asian or Indo-Caribbean Southeast Asian White Mixed Race Prefer not to answer Other  Select All

Do you identify as a person with a disability? (This may include physical, mental health, learning, cognitive, sensory, chronic illness, neurodivergent, visible, or non-visible disabilities.)

Yes      No      Prefer not to answer

What other languages do you speak?

English French Other*  Albanian Amharic Arabic Armenia Bengali Cantonese Creole Dari Dutch Farsi Mandarin Mbo Nepali Pashto Punjabi Russian Somali Spanish Swahili Tagalog Tamil Telegu Tibetan Tigrigna Turkish Twi Ukraine Urdu Vietnamese Zulu Other Gujarati Hindi Italian Korean Ndebele Malayalam Hindi Assyrian Gujarati Kiswahili Korean Japanese Punjabi Select All

How did you hear about the JUMP program?

Family/Friends Another YWCA program Another Employment Ontario Program Another Settlement Program Educational Institution Internet/Website Newsletter Other  Select All

What describes your current situation?

Working - Part time Working - Casual Working - Full Time Working - Self Employed Student - Full time Student - Part time Student - Attending LINC level  Other - Not Working Other - Volunteering Other - Other  Select All

What is your current source of income?

Savings Family support Ontario Works/ODSP Employment Insurance Employed Part-time Employed Full-time Employment Select All

Highest Level of Education

High School College University Other training/education No formal Education Elementary

Privacy Statement The staff at YWCA JUMP program respect your privacy and the information that you share with us. We will use your personal information for registration purposes as well as to provide appropriate and effective services for you. All written information will only be seen by YWCA JUMP staff and our funder, Immigration, Refugees and Citizenship Canada (IRCC). We will not share any of your personal information beyond the YWCA JUMP staff and our funder unless you agree and sign “Consent to Release Information�, or in some special situations. You can ask to see your file and/or have a copy at any time.

I have read and understand the Privacy Statement written above, regarding how my personal information will be recorded and used by the YWCA JUMP staff and Immigration, Refugees and Citizenship Canada.

Yes      No

Consent Statement Immigration, Refugees and Citizenship Canada (IRCC) may want to contact you in the future. They will ask only about IRCC services, including services you receive from our organization, and if these services were useful to you and helped you settle in Canada. IRCC will use your answers, and answers from other immigrants, to improve services for all immigrants. This is voluntary: you are not obligated to answer IRCC’s questions. IRCC will not use your information to make any decisions about you personally.

Click >>>here<<< to read this Consent Statement in multiple languages

Thank you for completing the form. We will contact you shortly. In the meantime, if you have any questions, you can reach us by email at jumpetobicoke@@ywcatoronto.org or by phone at 416-964-3883.

Can IRCC, or an independent research company acting for IRCC, contact you in future?

Yes      No

Would you like to receive emails from the YWCA Toronto?

No