NAIS 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-LawDivorcedMarriedSeparatedSingleWidowedGender(Required)FemaleMaleNon-BinaryPrefer not to sayUnknownLevel of EducationHigh School or LowerPre-university/Post SecondaryCertificate/Diploma/ApprenticeshipBachelor DegreeMaster DegreePh.D.OtherEmail Address(Required) Phone Number(Required)Secondary PhoneNative 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 #CityNeepawaArborgAnolaAshernBeausejourEriksdaleFisher BranchFraserwoodGimliHodgsonIle Des ChenesKomarnoLa BroquerieLac du BonnetNivervilleOakbankPinawaPine FallsRicherRivertonSelkirkSeven Sister FallsSt-Pierre-JolysSt. AdolpheSt. MaloSte. AnneStonewallTeulonWhitemouthWinnipeg BeachAgassiz Provincial ForestAlexanderAlonsaAltonaAubignyAustinBaldurBasswoodBelmontBenitoBerens RiverBeulahBinscarthBirnieBirtleBissettBlumenortBoissevainBrandonBrochetBrookdaleBrunkildCampervilleCarberryCarmanCartwrightChurchillCooks CreekCormorantCowanCranberry PortageCrandallCross LakeCrystal CityCypress RiverDarlingfordDauphinDeloraineDominion CityDufresneDugaldEast BraintreeEastervilleEddystoneEdenEdwinElginElieElkhornElm CreekElmaEmersonEricksonEthelbertFalcon LakeFisher RiverFlin FlonFork RiverFoxwarrenGardentonGilbert PlainsGillamGirouxGladstoneGlenboroGlenellaGods Lake NarrowsGrand BeachGrand RapidsGrandviewGretnaGrunthalGypsumvilleHadashvilleHamiotaHartneyHazelridgeHeadingleyHeclaHollandIlfordInwoodIsland LakeKelwoodKentonKillarneyKleefeldKolaLa SalleLac BrochetLandmarkLangruthLeaf RapidsLibauLindenLittle Grand RapidsLockportLoretteLowe FarmLundarLynn LakeMacGregorMafekingManigotaganManitouMarchandMcAuleyMcCrearyMelitaMiamiMiddlebroMiniotaMinnedosaMintoMitchellMoose LakeMordenMorrisNelson HouseNewdaleNorway HouseNotre Dame de LourdesOak LakeOak RiverOakvilleOchre RiverOtterburneOxford HousePansyPeguisPelican RapidsPikwitoneiPilot MoundPine DockPine RiverPineyPlum CouleePlumasPointe du BoisPoplar RiverPoplarfieldPortage la PrairiePrawdaRandolphRapid CityRathwellRed Sucker LakeRennieRestonRiversRoblinRolandRorketonRosaRoseau RiverRosenortRosewoodRossRossburnRussellSandilandsSandy LakeSanfordSartoSchanzenfeldShamattawaShiloShoal LakeSidneySiftonSnow LakeSnowflakeSomersetSourisSouth Indian LakeSouth JunctionSperlingSplit LakeSpragueSt. ClaudeSt. Francois XavierSt. Jean BaptisteSt. LaurentSt. LazareStarbuckSte. AgatheSteinbachSte. Rose du LacSteep RockStrathclairSundownSwan LakeSwan RiverTadoule LakeThe PasThicket PortageThompsonTolstoiTourondTreherneTyndaleVassarVirdenVitaWaasagomachWabowdenWanlessWasagamingWaterhenWawanesaWinklerWinnipegWinnipegosisWoodlandsWoodmoreWoodridgeZhodaProvince(Required)ManitobaPostal Code(Required)Immigration Related InformationStatus in Canada(Required)Canadian CitizenGovernment Assisted Refugees (GAR)Permanent ResidentStudent - Study PermitVisitor Visa - Temporary Resident VisaWork PermitNo StatusUkraine CUAET PermitProvincial Nominee (PNP)Naturalized CitizenTemporary Foreign Worker (closed work permit)Work Permit (Open)UCI/IUC (Unique Client Identifier)(Required)UCI/IUC (Unique Client Identifier)Country of BirthAfghanistanAlbaniaAlderneyAlgeriaAmerican 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 Date of becoming PR 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-inImmigration DocumentThis can be a Confirmation of Permanent Residence, a Work Permit, a Refugee Claimant document, a Permanent Resident Card, etc.If uploading a Permanent Resident Card or other two-sided document, please ensure both sides are attached. Drop files here or Select files Accepted file types: pdf, docx, doc, jpg, gif, tiff, Max. file size: 10 MB, Max. files: 1. Emergency Contact InformationFull Name(Required)Phone Number(Required)Email(Required) Additional InformationThis field is hidden when viewing the formWhich type of services are you interested in:(Required)Settlement ServicesSchool Related Services (SWIS)EmploymentYouth ProgramWould 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 Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Canadian CitizenGovernment Assisted Refugees (GAR)Permanent ResidentStudent - Study PermitVisitor Visa - Temporary Resident VisaWork PermitNo StatusUkraine CUAET PermitProvincial Nominee (PNP)Naturalized CitizenTemporary Foreign Worker (closed work permit)Work Permit (Open)Gender(Required)FemaleMaleNon-BinaryPrefer not to sayUnknownMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedRelationship(Required)SpouseChildSiblingParentCommon Law SpouseUCI/IUC (Unique Client Identifier)Member 2First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Canadian CitizenGovernment Assisted Refugees (GAR)Permanent ResidentStudent - Study PermitVisitor Visa - Temporary Resident VisaWork PermitNo StatusUkraine CUAET PermitProvincial Nominee (PNP)Naturalized CitizenTemporary Foreign Worker (closed work permit)Work Permit (Open)Gender(Required)FemaleMaleNon-BinaryPrefer not to sayUnknownMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedRelationship(Required)SpouseChildSiblingParentCommon Law SpouseUCI/IUC (Unique Client Identifier)Member 3First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Canadian CitizenGovernment Assisted Refugees (GAR)Permanent ResidentStudent - Study PermitVisitor Visa - Temporary Resident VisaWork PermitNo StatusUkraine CUAET PermitProvincial Nominee (PNP)Naturalized CitizenTemporary Foreign Worker (closed work permit)Work Permit (Open)Gender(Required)FemaleMaleNon-BinaryPrefer not to sayUnknownMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedRelationship(Required)SpouseChildSiblingParentCommon Law SpouseUCI/IUC (Unique Client Identifier)Member 4First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Canadian CitizenGovernment Assisted Refugees (GAR)Permanent ResidentStudent - Study PermitVisitor Visa - Temporary Resident VisaWork PermitNo StatusUkraine CUAET PermitProvincial Nominee (PNP)Naturalized CitizenTemporary Foreign Worker (closed work permit)Work Permit (Open)Gender(Required)FemaleMaleNon-BinaryPrefer not to sayUnknownMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedRelationship(Required)SpouseChildSiblingParentCommon Law SpouseUCI/IUC (Unique Client Identifier)Member 5First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Canadian CitizenGovernment Assisted Refugees (GAR)Permanent ResidentStudent - Study PermitVisitor Visa - Temporary Resident VisaWork PermitNo StatusUkraine CUAET PermitProvincial Nominee (PNP)Naturalized CitizenTemporary Foreign Worker (closed work permit)Work Permit (Open)Gender(Required)FemaleMaleNon-BinaryPrefer not to sayUnknownMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedRelationship(Required)SpouseChildSiblingParentCommon Law SpouseUCI/IUC (Unique Client Identifier)Member 6First Name(Required)Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Status in Canada(Required)Canadian CitizenGovernment Assisted Refugees (GAR)Permanent ResidentStudent - Study PermitVisitor Visa - Temporary Resident VisaWork PermitNo StatusUkraine CUAET PermitProvincial Nominee (PNP)Naturalized CitizenTemporary Foreign Worker (closed work permit)Work Permit (Open)Gender(Required)FemaleMaleNon-BinaryPrefer not to sayUnknownMarital Status(Required)Common-LawDivorcedMarriedSeparatedSingleWidowedRelationship(Required)SpouseChildSiblingParentCommon Law SpouseUCI/IUC (Unique Client Identifier)Consents and Confidentiality StatementI consent to be added to the mailing list for information on events and workshops.(Required)YesNoFor purposes related to display, advertising, and reporting to funders, I, on behalf of myself and all family members included in this intake, consent to photos and videos being taken by NAISS.(Required)YesNoI consent to your organization collecting, storing, and using my personal information for the purposes of providing services and communications related to events, workshops, and other relevant activities. I understand that appropriate security measures will be in place to protect my data from unauthorized access or misuse. I consent to the sharing of my personal information with trusted third-party partners of your organization solely for the purpose of delivering services and communications as described. I am aware that I have the right to withdraw my consent at any time, which may impact the services provided to me.Please either enter you initials here OR Sign in next boxSignature(Required)CaptchaThis field is hidden when viewing the formPrograms (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)This field is hidden when viewing the formDOC_1 TYPE
