Register for Housing Help Services

Given Name(s):

Family Name(s):*

Date of birth

Other

Email

Phone

Is there anything else you need to tell us about how to best contact you, such as best way and time?

OntarioBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutAlbertaPrince Edward IslandQuebecSaskatchewanYukon

Other

Number of children:

Other

Other

Ethno-racial Identification * —Please choose an option—Aboriginal/Indigenous (inside North America)Aboriginal/Indigenous (outside North America)African Ancestry – North AmericanAfrican Ancestry – CaribbeanAfrican Ancestry – Latin AmericanAfrican Ancestry – EuropeanAfrican Ancestry – Continental – North AfricaAfrican Ancestry – Continental – South AfricaAfrican Ancestry – Continental – East AfricaAfrican Ancestry – Continental – West AfricaLatin AmericanAsian – South AsianAsian – Southeast AsianAsian – West IndianAsian – FilipinoAsian – ChineseAsian – KoreanAsian – JapaneseMiddle Eastern – ArabMiddle Eastern – OtherWhite/Caucasian – North AmericanWhite/Caucasian – OtherUnknown/Choose not to identifyOther or Mixed Racial Heritage: Specify

Other

Preferred Language

Other

Special Needs/Accommodation Required

Please tell us the reason for connecting with us:

Referring Agency (if an agency is supporting a client in completing this form)

Referring Staff Person (if an agency is supporting a client in completing this form)