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VDICSS Client Intake Form

Your Personal Details

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Current Residential Address

Immigration Related Information

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Emergency Contact Information

Services

Would you require childcare services when accessing services at VDICSS?

Details of Family Members

Would you like to register your family members so that they can also receive services with us?

Member 1

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Member 2

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Member 3

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Member 4

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Member 5

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Member 6

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Consents and Confidentiality Statement

Mail Consent

Vernon and District Immigrant and Community Services Society (VDICSS) protects personal information by following the government's privacy laws as outlined in the Personal Information Act, Bill 38: https://www.bclaws.gov.bc.ca/civix/document/id/lc/billsprevious/4th37th:gov38-1

Staff will not disclose any information without client permission unless legally obligated to do so. Completion and submission of this intake form implies consent to collecting information for these purposes.

By signing below and submitting this form, you confirm that you have read the Gathering Information statement and has given consent to future Immigration, Refugees, and Citizenship Canada Research/Consultation.

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100, 3003 30 St, Vernon, British Columbia V1T9J5 Canada

(250) 542-4177 |

vdicss@vdicss.org

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