Online Intake Form
  • Date
     - -

  • Client Intake Form

  • Principal Applicant

  • Birthdate*
     - -
  • Date of Arrival in Canada *
     - -
  • Date of Arrival in Saint John*
     - -

  • Error: The Date of Arrival in Saint John can't be sooner then Date of Arrival in Canada. 

  • Date of Expiry
     - -

  • Type of Applicant:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is your Main Reason for Wanting to Learn English?
  • Date:
     - -
  • Do you need the service of an employment specialist?*

  • Family Member 1st

  • Birthdate (1st)*
     - -
  • Date of Arrival in Canada (1st) *
     - -
  • Date of Arrival in Saint John (1st)*
     - -

  • Error: The Date of Arrival in Saint John can't be sooner then Date of Arrival in Canada. 

  • Error: The UCI/PR Number you entered is already used for another Family Member. 

  • Date of Expiry (1st)
     - -

  • Type of Applicant:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is your Main Reason for Wanting to Learn English? (1st)
  • Date: (1st)
     - -
  • Do you need the service of an employment specialist (1st)?*

  • Family Member 2nd

  • Birthdate (2nd)*
     - -
  • Date of Arrival in Canada (2nd) *
     - -
  • Date of Arrival in Saint John (2nd)*
     - -

  • Error: The Date of Arrival in Saint John can't be sooner then Date of Arrival in Canada. 

  • Error: The UCI/PR Number you entered is already used for another Family Member. 

  • Date of Expiry (2nd)
     - -

  • Type of Applicant:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is your Main Reason for Wanting to Learn English? (2nd)
  • Date: (2nd)
     - -
  • Do you need the service of an employment specialist (2nd)?*

  • Family Member 3rd

  • Birthdate (3rd)*
     - -
  • Date of Arrival in Canada (3rd)*
     - -
  • Date of Arrival in Saint John (3rd)*
     - -

  • Error: The Date of Arrival in Saint John can't be sooner then Date of Arrival in Canada. 

  • Error: The UCI/PR Number you entered is already used for another Family Member. 

  • Date of Expiry (3rd)
     - -

  • Type of Applicant:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is your Main Reason for Wanting to Learn English? (3rd)
  • Date: (3rd)
     - -
  • Do you need the service of an employment specialist (3rd)?*

  • Family Member 4th

  • Birthdate (4th)*
     - -
  • Date of Arrival in Canada (4th) *
     - -
  • Date of Arrival in Saint John (4th)*
     - -

  • Error: The Date of Arrival in Saint John can't be sooner then Date of Arrival in Canada. 

  • Error: The UCI/PR Number you entered is already used for another Family Member. 

  • Date of Expiry (4th)
     - -

  • Type of Applicant:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is your Main Reason for Wanting to Learn English? (4th)
  • Date: (4th)
     - -
  • Do you need the service of an employment specialist (4th)?*

  • Family Member 5th

  • Birthdate (5th)*
     - -
  • Date of Arrival in Canada (5th)*
     - -
  • Date of Arrival in Saint John (5th)*
     - -

  • Error: The Date of Arrival in Saint John can't be sooner then Date of Arrival in Canada. 

  • Error: The UCI/PR Number you entered is already used for another Family Member. 

  • Date of Expiry (5th)
     - -

  • Type of Applicant:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is your Main Reason for Wanting to Learn English? (5th)
  • Date: (5th)
     - -
  • Do you need the service of an employment specialist (5th)?*

  • Consent

    By clicking submit, I give the YMCA of Great Saint John permission to use this information provided to contact me.

  • CONSENT FORM

     

    I authorize the YMCA of Greater Saint John to collect and share my personal information for the purpose of assisting me with my immigration and settlement needs and assisting me in attaining my personal, employment or training goals or contacting me to monitor my status on an ongoing basis (for up to 7 years following my participation in any program).

     

    The information may also be used to compile statistical reports, refer you to suitable/required agencies or to measure and evaluate program activities.

     

    I understand that my information will be shared with government immigration departments (IRCC or PETL) or with other departments/agencies as required by government or by law. I understand that my information may be kept as hard copies at the YMCA or digitally on a local or remote computer server. I understand that I have the right to view all records and information held by the YMCA that applies specifically to me. This authorization may be revoked, in writing only, at any time but doing so will affect my ability to further participate in programs or activities.

     

    I understand that my permanent resident number and birthdate will be shared with CCNB if I am referred for a language assessment.

     

    I will inform newcomer connections if my status Change.


    I understand the above information, or have been given the opportunity to read it in my own language, if needed. I also have read and understand the IRCC “Gathering Information” and “Consent Statement”.

  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Clear
  • Date
     - -

  • MINOR CONSENT FORM

  • hereby voluntarily authorize the YMCA of Greater Saint John to collect and share personal information of the following individuals who are under the legal age of majority (19 years old):

  • For the purpose of: assisting me with their immigration and settlement needs, assisting them in attaining their personal, employment or training goals or contacting them to monitor their status on an ongoing basis (until the age of majority). The information may also be used to compile statistical reports, refer them to suitable/required agencies or to measure and evaluate program activities. The information will be shared with government immigration departments (IRCC or PETL) or with other departments/ agencies as required by agreement or by law. Their information may be kept as hard copies on our premises or digitally on a local or remote computer server. You or they have the right to view all records and information held by us that applies specifically to them. This authorization may be revoked, in writing only, at any time but doing so will affect my ability to further participate in programs or activities.

  • Clear
  • Date
     - -
  • Should be Empty: