HEAL Network Workshops 2023/24 Registration Form | MIAG Centre

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First Name

Last Name

Email:

Address

City:

Organization (if applicable)

Postal Code

Phone:

Cell Phone:

Gender:

Male

Female

Trans-female to male

Trans-male to female

Intersex

Prefer not to answer

Do not know

Age Group:

18 - 25

26 - 34

35-44

45-54

55-64

65+

Racial/ Ethnic Background

Asian-East (e.g. Chinese, Japanese, Korean)

Asian-South (e.g. Indian, Pakistani, Sri Lankan)

Asian-South East (e.g. Asian, Filipino, Vietnamese)

Black-African (e.g. Ghanaian, Kenyan, Somali)

Black-Caribbean (e.g. Barbadian, Jamaican, Guyanese)

Indian Caribbean (e.g. Guyanese with origins in India)

First Nations-Non-Status

First Nations-Status

Indigenous/ Aboriginal not included elsewhere

Inuit

Latin American (e.g. Argentinian, Chilean, Salvadoran)

Middle-Eastern (e.g. Egyptian, Iranian, Lebanese)

White-European (e.g. English, Italian, Portuguese, Russian)

White-North American (Canadian, American)

Mixed Heritage (e.g. Black African and White N. American)

Prefer Not to Answer

Other Not Listed Above (Please specify)

How Long have you been in Canada?

0 - 3 years

4 - less than 5 years

5 - less than 10 years

10 years and more

Canadian born

What is your status in Canada?

Temporary Resident

Refugee Claimant

Convention Refugee

Government-Assisted Refugees Program (GAR)

Permanent Resident

Canadian Citizen

Marital Status

Never married (single)

Married

Common law

Separated

Divorced

Widow

Signature: Name and Last Name

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