Families and Schools Together - Family Services York Region

School Name:*

Family Last Name:*

Address*

Street Address City Province Postal Code

Phone*

Okay to Leave Voicemail?*

Yes

No

Parent/Guardian Email*

Enter Email Confirm Email

Okay to Send Email?*

Yes

No

Information About Your Family Household:

Please Identify How Many Family Members in Your Household*

2 Household Members

3 Household Members

4 Household Members

5 Household Members

6 Household Members

Household Family Member – One

Name*

First Last

Date of Birth*

Relationship in Family*

(Example: sister, brother, mom, dad)

School Grade*

(Example: Grade 4 or N/A if not school age)

Age*

Gender*

Pronouns*

(he, she, they, etc.)

Will Family Member Attend?*

Yes

No

Additional Family Member – Two

Name*

First Last

Date of Birth*

Relationship in Family*

(Example: sister, brother, mom, dad)

School Grade*

(Example: Grade 4 or N/A if not school age)

Age*

Gender*

Pronouns*

(he, she, they, etc.)

Will Family Member Attend?*

Yes

No

Additional Family Member – Three

Name*

First Last

Date of Birth*

Relationship in Family*

(Example: sister, brother, mom, dad)

School Grade*

(Example: Grade 4 or N/A if not school age)

Age*

Gender*

Pronouns*

(he, she, they, etc.)

Will Family Member Attend?*

Yes

No

Additional Family Member – Four

Name*

First Last

Date of Birth*

Relationship in Family*

(Example: sister, brother, mom, dad)

School Grade*

(Example: Grade 4 or N/A if not school age)

Age*

Gender*

Pronouns*

(he, she, they, etc.)

Will Family Member Attend?*

Yes

No

Additional Family Member – Five

Name*

First Last

Date of Birth*

Relationship in Family*

(Example: sister, brother, mom, dad)

School Grade*

(Example: Grade 4 or N/A if not school age)

Age*

Gender*

Pronouns*

(he, she, they, etc.)

Will Family Member Attend?*

Yes

No

Additional Family Member – Six

Name*

First Last

Date of Birth*

Relationship in Family*

(Example: sister, brother, mom, dad)

School Grade*

(Example: Grade 4 or N/A if not school age)

Age*

Gender*

Pronouns*

(he, she, they, etc.)

Will Family Member Attend?*

Yes

No

Other Information:

What is Your Country of Origin?*

Race*

(Examples: Black, South-East Asian, White)

Ethnicity*

(Examples: Canadian, African, Iranian)

How Long Has Your Family Been in Canada?*

Less than 10 years

More than 10 years

Primary Language?*

Secondary Language?*

Do you or any participating members identify as First Nations, Inuit or Metis?*

Yes

No

If Yes, Please Indicate the Band Name.

What is Your Annual Gross Household Income?*

Note: this information is purely for funding purposes

Any Allergies in the Family?*

Are you available and can you commit to attend all 8 weeks?*

List Family Interests and Suggestions for Prizes for Each Member:*

(Examples:) For children: toys, books, clothing, arts and crafts items that they may enjoy. For adults: books, self-care items (make up, bath items, lotions), small outdoor items that the adults may enjoy. **There is no guarantee of any of these items and we will do our best to find matches for the items listed above.

Team Visitor Name:

Date

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Families and Schools Together Application Form

Information About Your Family Household:

Household Family Member – One

Additional Family Member – Two

Additional Family Member – Three

Additional Family Member – Four

Additional Family Member – Five

Additional Family Member – Six

Other Information: