Intake application | Talitha Koum Society

First name^*

Last name^*

Middle name

Preferred name

Date of birth^*

Gender

Pronouns

Marital status

Email

Home phone

Cell phone

Address

City

Province

Postal code

Demographics

Ethnicity

Preferred language

Secondary language

Religion

Citizenship status

Indigenous status

Indigenous

Indigenous identity

Band / First Nation

Reserve name

Lives on reserve

Status card number

Treaty number

Métis membership number

Inuit land claim area

Emergency contacts^*

First name^*

Last name^*

Date of birth

Relationship

Home phone

Work phone

Cell phone

Email

Address

Address

City

Province

Postal code

Organization

Title

Notes

Family & Support contacts

Employment

SIN

Employment status

Employer name

Occupation

Education

Education level

Institution name

Graduation year

Is this a referral?

Referral date

Referral source

Referral contact

Referral phone

Referral email

Referral reason

Referral notes

Consent agreement

By submitting this enrolment application, I consent to the collection, use, and storage of the personal information provided in this form by Talitha Koum Society for the purpose of assessing eligibility, processing enrolment, and delivering care services. The information collected may include personal identifiers, contact details, demographic information, Indigenous status, emergency contacts, employment and education history, and referral details.

This information will be:

Used to evaluate and process this enrollment application
Shared with authorized staff involved in care planning and service delivery
Stored securely in accordance with applicable privacy legislation

This information is collected under the authority of the Personal Information Protection Act (PIPA) of British Columbia and is managed in compliance with applicable federal and provincial privacy laws, including PIPEDA.I understand that:

Providing this information is voluntary, though incomplete applications may affect eligibility assessment
I may withdraw this application at any time by contacting the organization
I have the right to request access to, or correction of, my personal information
This consent applies to the enrollment process only — separate consent will be obtained for care-related data collection.

For questions about how your information is handled, contact the organization's Privacy Officer.

Consent acknowledged

I acknowledge that the applicant has been informed about data collection and consents to the processing of their personal information.