Intake Form Regina

Personal Information

Name (on ID) *

First

Last

Gender *

Pronoun *

Date of Birth *

What languages do you speak? *

Contact Information

City *

Home Address

Postal Code

Email *

Phone *

Immigration Information

When did you arrive to Saskatchewan? *

Would you like our staff to contact you to book an appointment?

Yes
No

CONSENT AND DECLARATION

By typing my name below, I acknowledge that the information collected during this assessment will only be used by International Women of Saskatoon (IWS) Inc. for the purpose of registration and referral, and will be shared only with Immigration, Refugees and Citizenship Canada (IRCC) and the Service Providing Organizations where client was referred. *

I consent to receive emails from IWS about upcoming events and free programs *

Yes
No

I agree to allow Immigration, Refugees and Citizenship Canada (IRCC) to contact me in the future regarding my settlement and language progress. *

Yes
No

For the purpose of reporting and to bring life to the stories that IWS provides to members, clients and the community, IWS staff will take photos and record videos of participants at various IWS programs and events. We would like to share these media items on the IWS website, Facebook page, and advertising materials including, but not limited to: bulletins, posters, brochures, and newsletters. By signing below, I give permission to IWS to use or publish photographs at its discretion. I also acknowledge that IWS may choose not to use my photographs at this time, but may do so at its own discretion at a later date. I acknowledge that since participation is voluntary, neither my minor child(ren) nor I will receive financial compensation. Therefore, I agree to indemnify and hold harmless IWS, its Board, and Staff from any claims arising from the use of my photographs. IWS reserves the right to discontinue use of any photographs without notice. I understand that it is my responsibility to give notice to IWS staff and the photographer if I wish to abstain from the photos being taken during programs and events. *

I have read and understand the above terms and consent to have my photo taken by IWS
I have read and understand the above terms and DO NOT consent to have my photo taken by IWS. I will give notice to the photographer and remove myself from pictures

Signature *

By signing this form, I declare that the information provided on the registration form above is accurate and true to the best of my knowledge.