Unpack N' Play Registration Form

Parent's Name

Email

Age range

Phone

Postal Code

For each child you are registering (including newborns and babies) please write their name/s and age/s

Location/Zoom Day

Please check if the following applies to you:

Indigenous‎ Single Parent‎ Low Income Family‎ Non Indigenous Person of Color/Racialized Individual‎

What is your mobility status:

Non-migrants Internal Migrants (from within Canada) External Migrants (from outside of Canada)

Gender Identity (optional). I identify as:

Female Male Other

Do you have any concerns about your family functioning (i.e. new baby, job loss, parents back to work, etc.)? How has your family been impacted by COVID-19? What challenges is your family facing, if any?

How do you feel City West could provide you the support you might need in regards to parenting/child development/family functioning/etc. What are you hoping to gain from the program?

Do you have any concerns about your child's health or development?

Have you participated in Unpack N' Play this calendar year?

Yes No

Comments
E.g. other days that would work for you, potential missing sessions, if you are expecting a baby during the 12 weeks of the program, who will be attending the program (yourself, your spouse, grandparent/s, etc.), etc.