VDICSS Intake Form VDICSS Client Intake Form Your Personal DetailsFirst Name(Required)Middle NameLast NamePreferred/Other NameDate of Birth(Required) DD slash MM slash YYYY Marital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedUnknownGender(Required)FemaleMaleUnknownNon-BinaryLevel of EducationNo SchoolingPrimary EducationHigh School or LowerPre-university/Post SecondaryCertificate/Diploma/ApprenticeshipBachelor DegreeMaster DegreePh.D.Email Address(Required) Phone Number(Required)Secondary PhonePreferred Language(Required)EnglishFrenchAfrikaansAlbanianAmharicArabicArmenianBengaliBisayaBurmeseCantoneseCatalanCebuanoChineseChinese - SimplifiedChinese - TraditionalCreoleCroatianCzechDanishDutchFarsi (Persian)FilipinoGermanGujaratiHiligaynonHindiHungarianIlicanIlocanoIndonesianItalianItsekiriJapaneseKarenKinyarwandaKoreanMalagasyMalayalamMandarinMarathiMizoNepaliOther Middle Eastern LanguagesPashtoPolishPortuguesePunjabiRomanianRussianSerbianShonaSinhaleseSloveneSomaliSpanishSwahiliTagalogTamilTeluguThaiTigrignaTurkishUkrainianUrduVietnameseYorubaAcholiAdaAffarAfghanAkaAkanAklanonAkraAmerican Sign Language (ASL)Anuak (Anywa)AranAshantiAssameseAssyrianAzeriBahasa IndonesianBalochiBambaraBamileke / GhomalaBansoBantuBauleBelarusianBelenBembaBembeBeniBeninBerberBetiBhariBicol/Bikol/BicolanoBijaiyaBilenBiniBissaBontokBraille (translation only)BretonBulgarianBurji / Bembala / Bambala / DaashiBusanBusangoChakmaChaldeanChaochoChavacanoChichewaChinChiuchowChiyaoChowchauConcaniCreeDagaareDariDaza / Dazaga / TebuDinkaDioulaDzongkhaEdoEfikEsanEstonianEweFangFantiFe'fe / Fe'efe'e / Nufi / BafangFinnishFlemishFoochowFoukiFoullahFukineseFulaniGaGaelicGeorgianGrebo/KrumenGreekGuerzeHainamHakha ChinHakkaHararaHararyHargarHassanyaHausaHebrewHindkoHokkinIbibioIboIcelandicIdomaIgboIgorotIjawIkaIlongoIshanIvbiosakonIziJaraiJavaneseJingpoJolayJuba ArabicKacchiKakwaKanareseKandahariKankaniKannadaKapampanganKashmiriKazakhKenyang / Nyang / Banyang / ManyangKhmerKifuliruKihavuKihemba/Hemba/Kiluba-HembaKikambaKikongoKinnauriKinyamulengeKiregaKirundiKiswahiliKitubaKonkaniKpelleKrioKurdishKurmanjiKyrgyzLa langue des signes québécoise (LSQ)LaotianLariLatvianLebaneseLengieLingalaLithuanianLowmaLugandaLugishuLutoroMabanMacedonianMacenaMacuaMahouMakondeMalayMaligoMalinkeMalteseMandeMandingoMasalitMashiMendeMinaMoldovanMongolianMooreNaandi/CemualNdebeleNgiemboonNgombaNorwegianNubianNuerNzimaOkoOkpeOriyaOromoOsalOther African LanguagesOther Chinese DialectsOther European LanguagesOther LanguagesOther Signed LanguagesOther South Asian LanguagesOther South East Asian Lang.OtuhoPahariPampangoPangasinanPeulPhuockienPidginPlautdietschPoularRohingyaRomaniRukigaRunyankoleRutooroSahoSamoanSangoSanskritSaraScoulaSechuanSenufoSerbo-CroatianSesothoSeswiSeychellesShanShanghaiShansaiShillukSign LanguageSindhiSlovakSonghaiSoninkeSoraniSothoSoussouSouthern BurunSuesueSukumaSwazaiSwedishSwiss GermanTaichewTamasheqTariTatarTatshaneseTemneTeochewTibetanTichiewTigreTiminiTivToishanTshilubaTsibulaTwiUdukUhroboUigrigmaUmbunduUnamaUnknownUyghurUzbekVisayanWarayWelshWestern Hemisphere Indian LangWolofXhosaYacoubaYako/Loko/LokaaYekhee/Afenmai/AfemaiYiboeYiddishZandeZshilubaZugandaZuluOther Spoken Languages (if applicable)EnglishFrenchAfrikaansAlbanianAmharicArabicArmenianBengaliBisayaBurmeseCantoneseCatalanCebuanoChineseChinese - SimplifiedChinese - TraditionalCreoleCroatianCzechDanishDutchFarsi (Persian)FilipinoGermanGujaratiHiligaynonHindiHungarianIlicanIlocanoIndonesianItalianItsekiriJapaneseKarenKinyarwandaKoreanMalagasyMalayalamMandarinMarathiMizoNepaliOther Middle Eastern LanguagesPashtoPolishPortuguesePunjabiRomanianRussianSerbianShonaSinhaleseSloveneSomaliSpanishSwahiliTagalogTamilTeluguThaiTigrignaTurkishUkrainianUrduVietnameseYorubaAcholiAdaAffarAfghanAkaAkanAklanonAkraAmerican Sign Language (ASL)Anuak (Anywa)AranAshantiAssameseAssyrianAzeriBahasa IndonesianBalochiBambaraBamileke / GhomalaBansoBantuBauleBelarusianBelenBembaBembeBeniBeninBerberBetiBhariBicol/Bikol/BicolanoBijaiyaBilenBiniBissaBontokBraille (translation only)BretonBulgarianBurji / Bembala / Bambala / DaashiBusanBusangoChakmaChaldeanChaochoChavacanoChichewaChinChiuchowChiyaoChowchauConcaniCreeDagaareDariDaza / Dazaga / TebuDinkaDioulaDzongkhaEdoEfikEsanEstonianEweFangFantiFe'fe / Fe'efe'e / Nufi / BafangFinnishFlemishFoochowFoukiFoullahFukineseFulaniGaGaelicGeorgianGrebo/KrumenGreekGuerzeHainamHakha ChinHakkaHararaHararyHargarHassanyaHausaHebrewHindkoHokkinIbibioIboIcelandicIdomaIgboIgorotIjawIkaIlongoIshanIvbiosakonIziJaraiJavaneseJingpoJolayJuba ArabicKacchiKakwaKanareseKandahariKankaniKannadaKapampanganKashmiriKazakhKenyang / Nyang / Banyang / ManyangKhmerKifuliruKihavuKihemba/Hemba/Kiluba-HembaKikambaKikongoKinnauriKinyamulengeKiregaKirundiKiswahiliKitubaKonkaniKpelleKrioKurdishKurmanjiKyrgyzLa langue des signes québécoise (LSQ)LaotianLariLatvianLebaneseLengieLingalaLithuanianLowmaLugandaLugishuLutoroMabanMacedonianMacenaMacuaMahouMakondeMalayMaligoMalinkeMalteseMandeMandingoMasalitMashiMendeMinaMoldovanMongolianMooreNaandi/CemualNdebeleNgiemboonNgombaNorwegianNubianNuerNzimaOkoOkpeOriyaOromoOsalOther African LanguagesOther Chinese DialectsOther European LanguagesOther LanguagesOther Signed LanguagesOther South Asian LanguagesOther South East Asian Lang.OtuhoPahariPampangoPangasinanPeulPhuockienPidginPlautdietschPoularRohingyaRomaniRukigaRunyankoleRutooroSahoSamoanSangoSanskritSaraScoulaSechuanSenufoSerbo-CroatianSesothoSeswiSeychellesShanShanghaiShansaiShillukSign LanguageSindhiSlovakSonghaiSoninkeSoraniSothoSoussouSouthern BurunSuesueSukumaSwazaiSwedishSwiss GermanTaichewTamasheqTariTatarTatshaneseTemneTeochewTibetanTichiewTigreTiminiTivToishanTshilubaTsibulaTwiUdukUhroboUigrigmaUmbunduUnamaUnknownUyghurUzbekVisayanWarayWelshWestern Hemisphere Indian LangWolofXhosaYacoubaYako/Loko/LokaaYekhee/Afenmai/AfemaiYiboeYiddishZandeZshilubaZugandaZuluCurrent Residential AddressAddress(Required)Apt/Unit #CityVernonArmstrongBurnabyCherryvilleColdstreamCranbrookEdgewoodEnderbyFalklandGrand ForksGrindrodKelownaLake CountryLumbyNelsonOsoyoosPeachlandPentictonPrince GeorgeRevelstokeSalmon ArmSicamousSilvertonSurreyVancouverWest KelownaWestbankWestwoldProvince(Required)British ColumbiaPostal Code(Required)Immigration Related InformationStatus in Canada(Required)Permanent ResidentPR - Approved in PrinciplePR - Other EconomicOther Humanitarian PathwayProvincial Nominee Awaiting PRCUAET Visa HolderOpen Work Permit HolderPost Graduate Work Permit HolderClosed Work Permit HolderTemporary Foreign WorkerStudy Permit Holder - International Post-Secondary StudentStudy Permit - MinorVisitor Visa - Temporary Resident VisaTemporary residentRefugee Claimant (RC)Canadian Citizen - By BirthNaturalized Canadian CitizenAsylum SeekerRNIPOtherUCI/IUC (Unique Client Identifier)(Required)UCI/IUC (Unique Client Identifier)Country of OriginAfghanistanAlbaniaAlderneyAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBritish Virgin IslandsBruneiBulgariaBurkina FasoMyanmar (formerly Burma)BurundiCameroonCanadaCanary IslandsCabo VerdeCayman IslandsCentral African RepublicChadChileChina (PRC)ColombiaComorosCongo Democratic Republic ofCongo (Congo Republic)Costa RicaCroatiaCubaCyprusCzechia (Czech Republic)DenmarkDjiboutiDominican RepublicEcuadorEgyptEl SalvadorEnglandEquatorial GuineaEritreaEstoniaEthiopiaGermanyFijiFinlandFr. PolynesiaFranceFrench GuianaGabonGambiaGeorgiaGhanaGreeceGreenlandGrenadaGuadaloupeGuamGuatemalaGuineaGuinea-bissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyCote d Ivoire (Ivory Coast)JamaicaJapanJordanKazakhstanKenyaKerguelen IslandsKyrgyzstanKiribatiKorea, NorthKorea, SouthKosovoKuwaitLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMoldovaMonacoMongoliaMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNorthern IrelandNorwayPakistanPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaScotlandSenegalSerbiaSeychellesSierra LeoneSingaporeSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Kitts and NevisSt. LuciaSt. Pierre Et MiquelonSt. Vincent And The GrenadinesStatelessSudanSurinameEswatini (formerly Swaziland)SwedenSwitzerlandSyriaTajikistanTanzaniaThailandTibetTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & CaicosTuvaluU.S. Virgin IslandsUnited States of AmericaUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuHoly See (Vatican City)VenezuelaVietnamWalesWestern SaharaYemenYugoslaviaZambiaZimbabweOmanSudan, SouthUnited KingdomSloveniaSlovakia (Slovak Republic)Taiwan (ROC)CambodiaDominicaEast Timor (Timor-Leste)MicronesiaMontenegroPalauDate of Arrival DD slash MM slash YYYY How Did You Hear About UsNot ReferredCommunity centre / libraryEmployer / co-workerEthnic or religious organizationFamily / friendsCanadian government agencyGovernment publication / brochure / websiteImmigration consultant / lawyerInternal to my organizationNon-governmental newspaper / media / publication / brochure / Web siteIn-Canada orientation sessionOverseas orientation session (e.g. CIIP)Other settlement service providerSchoolRecruitment via Destination Canada and Canadian embassiesRecruitment via website and social mediaWalk-inEmergency Contact InformationFull Name(Required)Phone Number(Required)Email(Required) ServicesWhich type of services are you interested in:(Required)Settlement ServicesSchool Related Services (SWIS)EmploymentLanguage SkillsCommunity EventsWould you require childcare services when accessing services at VDICSS? Yes No Would you like to provide any additional informationDetails of Family MembersWould you like to register your family members so that they can also receive services with us? Yes No How many members would you like to add?(Required)123456Member 1First Name(Required)Last NameDate of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Permanent ResidentPR - Approved in PrinciplePR - Other EconomicOther Humanitarian PathwayProvincial Nominee Awaiting PRCUAET Visa HolderOpen Work Permit HolderPost Graduate Work Permit HolderClosed Work Permit HolderTemporary Foreign WorkerStudy Permit Holder - International Post-Secondary StudentStudy Permit - MinorVisitor Visa - Temporary Resident VisaTemporary residentRefugee Claimant (RC)Canadian Citizen - By BirthNaturalized Canadian CitizenAsylum SeekerRNIPOtherGender(Required)FemaleMaleUnknownNon-BinaryMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedUnknownRelation with you(Required)Common Law SpousePartnerSpouseUnknownChildParentUCI/IUC (Unique Client Identifier)Member 2First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Permanent ResidentPR - Approved in PrinciplePR - Other EconomicOther Humanitarian PathwayProvincial Nominee Awaiting PRCUAET Visa HolderOpen Work Permit HolderPost Graduate Work Permit HolderClosed Work Permit HolderTemporary Foreign WorkerStudy Permit Holder - International Post-Secondary StudentStudy Permit - MinorVisitor Visa - Temporary Resident VisaTemporary residentRefugee Claimant (RC)Canadian Citizen - By BirthNaturalized Canadian CitizenAsylum SeekerRNIPOtherGender(Required)FemaleMaleUnknownNon-BinaryMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedUnknownRelation with you(Required)Common Law SpousePartnerSpouseUnknownChildParentUCI/IUC (Unique Client Identifier)Member 3First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Permanent ResidentPR - Approved in PrinciplePR - Other EconomicOther Humanitarian PathwayProvincial Nominee Awaiting PRCUAET Visa HolderOpen Work Permit HolderPost Graduate Work Permit HolderClosed Work Permit HolderTemporary Foreign WorkerStudy Permit Holder - International Post-Secondary StudentStudy Permit - MinorVisitor Visa - Temporary Resident VisaTemporary residentRefugee Claimant (RC)Canadian Citizen - By BirthNaturalized Canadian CitizenAsylum SeekerRNIPOtherGender(Required)FemaleMaleUnknownNon-BinaryMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedUnknownRelation with you(Required)Common Law SpousePartnerSpouseUnknownChildParentUCI/IUC (Unique Client Identifier)Member 4First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Permanent ResidentPR - Approved in PrinciplePR - Other EconomicOther Humanitarian PathwayProvincial Nominee Awaiting PRCUAET Visa HolderOpen Work Permit HolderPost Graduate Work Permit HolderClosed Work Permit HolderTemporary Foreign WorkerStudy Permit Holder - International Post-Secondary StudentStudy Permit - MinorVisitor Visa - Temporary Resident VisaTemporary residentRefugee Claimant (RC)Canadian Citizen - By BirthNaturalized Canadian CitizenAsylum SeekerRNIPOtherGender(Required)FemaleMaleUnknownNon-BinaryMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedUnknownRelation with you(Required)Common Law SpousePartnerSpouseUnknownChildParentUCI/IUC (Unique Client Identifier)Member 5First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Permanent ResidentPR - Approved in PrinciplePR - Other EconomicOther Humanitarian PathwayProvincial Nominee Awaiting PRCUAET Visa HolderOpen Work Permit HolderPost Graduate Work Permit HolderClosed Work Permit HolderTemporary Foreign WorkerStudy Permit Holder - International Post-Secondary StudentStudy Permit - MinorVisitor Visa - Temporary Resident VisaTemporary residentRefugee Claimant (RC)Canadian Citizen - By BirthNaturalized Canadian CitizenAsylum SeekerRNIPOtherGender(Required)FemaleMaleUnknownNon-BinaryMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedUnknownRelation with you(Required)Common Law SpousePartnerSpouseUnknownChildParentUCI/IUC (Unique Client Identifier)Member 6First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Permanent ResidentPR - Approved in PrinciplePR - Other EconomicOther Humanitarian PathwayProvincial Nominee Awaiting PRCUAET Visa HolderOpen Work Permit HolderPost Graduate Work Permit HolderClosed Work Permit HolderTemporary Foreign WorkerStudy Permit Holder - International Post-Secondary StudentStudy Permit - MinorVisitor Visa - Temporary Resident VisaTemporary residentRefugee Claimant (RC)Canadian Citizen - By BirthNaturalized Canadian CitizenAsylum SeekerRNIPOtherGender(Required)FemaleMaleUnknownNon-BinaryMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedUnknownRelation with you(Required)Common Law SpousePartnerSpouseUnknownChildParentUCI/IUC (Unique Client Identifier)Consents and Confidentiality StatementMail Consent I consent to be added to VDICSS's mailing list for information on events and workshops. 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.Please either enter you initials here OR Sign in next boxSignature(Required)CaptchaThis field is hidden when viewing the formProgram (Admin Only)This field is hidden when viewing the formDate Visited (Admin Only) DD slash MM slash YYYY This field is hidden when viewing the formOfficial Language (Admin Only)This field is hidden when viewing the formCurrent Emp Status (Admin Only)
