Orenda House Application FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastGender *MaleFemaleOtherOther (Please Specify)Do you identify as Indigenous? *YesNoWhat nation are you from? *Phone *Email *Date of Birth: (YYYY/MM/DD) *Marital Status *SingleMarriedDivorced/SeperatedCommon-lawWidowedPartner's NameNumber of children in your care & ages01234567899+Do you have a Children Services Worker? *YesNoIf yes, name and number of your workerAre you on Social Assistance? *YesNoI have an application being processedOther (AISH/EI/Youth in Care, etc)If yes, who is your worker and what is their contact information?If you're not on assistance, what is your other source of income?What is your monthly income? *Are you on E.I. (Employment Insurance)? *YesNoIf yes, when and why did you go on E.I.? Do you require childcare? *YesNoDo you use drugs or alcohol? *YesNoSometimesHow often do you use substances? *NeverA couple times a weekMost days of the weekEvery DayWhich community supports have you accessed in the last 6 months?Food BankFamily SupportsClothingHealth ClinicCollective kitchensHead StartFood CO-OPSParenting ProgramsEmployment ProgramsCoats for KidsCounsellingChurchFee Reduction ProgramEldersCultural SupportsSport CentralDaycareDaycare SubsidyWoman's Group SupportsMen's Group SupportsOtherNoneIf Other, please list: By clicking submit you recognize you are committing to sober living. Submit
