Blue Card Registration Link2Feed Registration "*" indicates required fields Please note that you must attach your identification and all requested supporting documents along with this application form in order for your application to be accepted. Please allow up to 2 weeks for your blue card to be available.Client Information & DemographicsFirst Name*Last Name*Gender IdentityMaleFemaleOtherDate of Birth* MM slash DD slash YYYY Phone*Confirm Phone*Email Address (including unit #)* Street Address City Postal Code No Fixed Address Identification File Upload* Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, word, Max. file size: 512 MB. Upload a picture of an acceptable ID for each individual in your household (birth certificate, driver's license, photo health card)Housing Type*Emergency ShelterPrivate RentalOwn HomeSocial HousingYouth ShelterUnhousedWith family/friendsPlease select one from the drop down list.Lived in Canada for 10 years or less?*YesNoPrefer not to answerReferred by:Dietary ConsiderationsNo dietary restrictionsDiabeticVeganVegetarianEgg AllergyGluten AllergyMilk AllergyPeanut AllergyWheat AllergyOtherRacial Identity*IndigenousWhiteBlackChineseFilipinoLatin AmericanAfricanSouth AsianSoutheast AsianWest AsianOtherHighest Level of Completed EducationPrefer not to answerGrade SchoolHigh SchoolCollegeUniversityDo you have a disability?*YesNoPrefer not to answerHousehold MembersList everyone in your household including yourself*Full NameDate of BirthGenderRelationship to youDoes this person have a disability? Add RemoveMonthly Income & ExpensesPlease list all income sources. At least 1 primary income source is required for the household*Income SourceIncome AmountWho Earned the Income? Add RemoveMonthly Housing Cost*Monthly Housing Type* Rent Mortgage Proof of income and residency upload* Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, word, Max. file size: 512 MB. Proof of income and residency is required. A photo or scan of your most recent OW/ODSP benefit stub (showing everyone in your household) , paycheck stub, and/or EI benefit stub are accepted. If you do not have access to any one of these documents, please connect with the Program Manager at 519-344-1746 x337.Consent to Disclose & Verify InformationPlease read the consent statement below. Signing/agreeing signifies that you understand this consent applies to yourself, your spouse or same-sex partner and child(ren) in your care.Consent* I agree to the privacy policy.Consent to Disclose and Verify Information Read through entire consent before filling out the signature portion above. Ontario Works Act, 1997 Ontario Disability Support Program, 1997 I understand that this consent applies to myself, my spouse or same-sex partner and child(ren) in my care. 1. I consent to the release of information to an authorized representative of The Inn of The Good Shepherd for the purpose of determining or verifying my initial or ongoing eligibility for assistance, related to services provided by this agency by collecting information about me and my household, and 2. I further consent to an authorized representative of The Inn of The Good Shepherd disclosing to any party personal information about me and my household for the purpose of determining or verifying my initial or ongoing eligibility for assistance or administering my assistance, related to service provided by this agency, and 3. I further consent to the exchange of information with an authorized representative of The Inn of The Good Shepherd or any party in order to verify information for the purposes of determining or verifying my initial or ongoing eligibility for and administration of my assistance related to services provided, and 4. I understand that this consent will apply to inquiries made relating to my initial eligibility for, as well as my past and ongoing participation in social programs. I further understand that the inquiries may take the form of electronic data exchanges. 5. I agree that above said agency may contact my Utility Company and/or landlord and may share/release information with the agencies in the interest of developing an action plan. * * Applicable only when applying for support through the Rent/Utility program. Staff will contact you at the phone number provided when your blue card is ready to be picked up at reception or Mobile Market. This may take up to 2 weeks. Thank you for your patience and understanding.Preferred pickup location Mobile Market Reception @ 115 John Street Δ
