Registration Form

West Nipissing Community Health Centre offers a variety of community programs. To register for one or more programs, please fill out the registration form. This information is kept confidential, and allows us to keep up to date information on our clients, as well as measure our impact on their wellbeing, and the wellbeing of our community.

Which program would you like to register for? *

Have you ever registered for a course / workshop / program offered by the West Nipissing Community Health Centre, either virtual or in person? *

I have already registered.
This is the first time that I register (note: you will only have to complete this form once).

Name *

First

Last

Email *

Address *

Town *

Phone Number *

I accept to receive emails as part of this course. *

Name *

First

Last

Date of Birth *

Home Phone Number *

Cell Phone or Other

Address *

Town *

Postal Code: *

Email *

Gender Identity: *

Male
Female
Intersex
Trans-Female to Male
Trans-Male to Female
Two-Spirit
Other
Do not know
Prefer not to answer

Sexual orientation: *

Bisexual
Gay
Heterosexual
Lesbian
Queer
Two-Spirit
Other
Do not know
Prefer not to answer

Highest education level attained *

Too young for primary completion
Primary (grades 1-8)
Secondary or equivalent
University Bachelor’s
University Post-Graduate
No formal education
Other
Do not know

Combined annual household income *

$0 – $14,999
$15,000 – $19,999
$20,000 – $24,999
$25,000 – $29,999
$30,000 – $34,999
$40,000 – $59,999
$60,000 – $89,999
$90,000 – $119,999
$120,000 – $149,999
$150,000 or more
Do not know
Prefer not to answer

Number of people supported by income *

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Do not know
Prefer not to answer

Current household composition *

Couple with children
Couple without child
Sole member
Grandparents with grandchild(ren)
Extended family
Unrelated housemates
Siblings
Single parent
Other
Do not know
Prefer not to answer

Homeless Status *

Not homeless
Homeless / no address
Shelter
Other Temporary

Spoken language (preferred) *

English
French
Other

Mother tongue/Language of origin

English
French
Other

Canada’s official language

English
French

Other language spoken:

Interpreter required for appointments *

Racial or ethnic group *

Asian – East
Asian – South
Asian – South East
Black African
Black Caribbean
Black – North American
First Nations
Indian -Caribbean
Indigenous/Aboriginal
Inuit
Latin American
Métis
Middle Eastern
White – European
White – North American
Mixed Heritage
Other
Do not know
Prefer not to answer

County of origin

Canada
Other

Date/year of arrival in Canada

Religion

Catholic
Protestant
Christian
Christian Orthodox
Muslim
Jewish
Buddhist
Mennonite
Hindu
Sikh
Eastern Religions
No religious affiliation
Other
Do not know
Prefer not to answer

Disability (check all that apply) *

None
Chronic illness
Developmental disability
Drug or alcohol dependence
Learning disability
Mental illness
Physical disability
Sensory disability
Other
Do not know
Prefer not to answer

How would you describe your sense of belonging to your community? A sense of belonging is feeling like you are part or something, connected and accepted. *

Very strong
Somewhat strong
Somewhat weak
Very weak
Do not know
Prefer not to answer

In general, how would you say your overall physical health is: *

Excellent
Very good
Good
Fair
Poor
Do not know
Prefer not to answer

In general, how would you say your overall mental health is: *

Excellent
Very good
Good
Fair
Poor
Do not know
Prefer not to answer

CONTACT PERSON OR PERSON TO CALL IN CASE OF EMERGENCY

Name *

Relationship: *

Phone Number: *

(Residential or mobile)

PAR-Q and You

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their health care provider before they start becoming much more physically active.

If you are planning to become much more physically active than you are now, start by answering the seven questions below. If you are between the age of 15 and 69, the PAR-Q will tell you if you should check with your health care provider before you start. If you are over 69 years of age, and you are not used to being very active, check with your health care provider.

Please answer “YES” or “NO” to the following questions:

Has your health care provider ever said that you have a heart conditions and that you should only do physical activity recommended by a doctor? *

Do you feel pain in your chest when you do physical activity? *

In the past month, have you had chest pain when you were doing physical activity? *

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Do you have a bone or joint problem (for example, back knee or hip) that could be made worse by a change in your physical activity? *

Is your health care provider currently prescribing medication (for example, water pills) for your blood pressure or heart condition? *

Do you know of any other reason why you should not do physical activity? *

**IF YOU ANSWERED YES TO ONE OR MORE OF THE ABOVE QUESTION**

Talk to your health care provider prior to starting any new physical activity.

Your Doctor or Nurse Practitioner is aware of your participation in these physical activities.

IF YOU HAVE ANY MEDIAL CONDITIONS, YOU ARE RESPONSIBLE TO ADVISE THE INSTRUCTOR AND HAVE ALL MEDICATIONS WITH YOU (ALLERGIES, DIABETES…)

CONSENT TO THE USE OF PHOTOS

On occasion, photos are taken during certain activities. These photos are kept at the West Nipissing Community Health Centre and may be used for advertising purposes.

Do you accept that photos be taken? *

I authorize the West Nipissing Community Health Centre to publish to photos and my name in the media. *

I accept to receive emails as part of this course. *

CONSENT TO COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION TO THE CLIENT The West Nipissing Community Health Centre (WNCHC) recognizes the importance of protecting your personal information and undertakes to collect, use and disclose your personal information in a fair and lawful manner by integrating best practice for the protection of the personal information, including information entrusted to a third party.

The WNCHC collects, uses and discloses information in order to:

• Provide and manage care services for safe primary health care;

• Establish and provide ongoing services and effective health care;

• Communicate with other service providers (with you approval);

• Evaluate and plan your health needs;

• Establish and maintain communication with you;

• Conduct research to improve the quality of health services and /or use the data collected for specific research;

• Meet all legal and regulatory requirements of the law;

Date: *

By submitting this form you indicate that you have read this form and that you agree with the principles as stated.

PAR-Q and You

Accessibility

Contact Us

Hours of Operation

Did you know that you can cancel your appointment online?

You will need to know your health card number and birth date.

It’s quick and easy!