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CAIFC General Intake Form
Date of Birth
MM slash DD slash YYYY
Please Specify Gender:
Status / Identity
Address Line 2
Newfoundland and Labrador
Prince Edward Island
Do You Know Which Program You Would Like To Contact?
I am not sure what Program
What Can We Help You With?
I agree to the Release of Liability Policy
I (“the Participant”), wish to participate in the (“the Program”), offered by The Can-Am Indian Friendship Centre of Windsor (“the Friendship Centre/Delivery Site”).
I have read and understand the rules and safety provisions established for the Program. I have had the opportunity to discuss with the Friendship Centre/Delivery Site any risks, dangers, or hazards to my person resulting from participation in the Program.
I am aware that my participation in the Program is voluntary. I freely accept and fully assume all such risks, dangers and hazards, the possibly of delay or inconvenience, Program cancellation of change, the loss of personal property, injury or death.
In consideration of the Friendship Centre/Delivery Site allowing my participation in the Program, I agree as follows:
1. Not to sue and to release and discharge the Friendship Centre/Delivery Site, its officers, agents and employees, from all liability to me, my personal representatives, heirs, and next of kin, for all loss or damage and to waive any claim or demands on account of my injury or death, or damage to my property arising out of my participation in the Program.
2. That this Agreement shall not apply to any personal or property damage sustained by me arising from the negligent acts or omissions of the Friendship Centre/Delivery Site.
3. To indemnify and hold harmless the Friendship Centre/Delivery Site from any loss, liability, damage or costs that I may incur due to my acts or omissions during participation in the Program.
4. That I agree to comply with the rules and safety provisions established for the Program.
5. To certify that I am physically fit and able to safely engage in the Program.
6. That in the event of any accident or sudden illness, the Friendship Centre/Delivery Site has my permission to have performed on me whatever medical emergency treatment may be deemed necessary.
7. That this Agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, assigns and representatives in the event of my death or incapacity.
I agree to the Personal Information & Consent Policy
The Notice and Consent is intended to inform you how The Can-Am Indian Friendship Centre of Windsor (“the Friendship Centre/Delivery Site”) will collect, use and disclose your personal information.
In order to provide programmes and services safely and efficiently, the Friendship Centre/Delivery Site requires certain pieces of personal information from you. The federal Personal Information Protection and Electronic Documents Act and equivalent provincial legislation requires that your consent be obtained prior to the collection and use of that information.
Your personal information may be collected formally, in writing, and informally, by the Friendship Centre/Delivery Site staff. This may include age, gender, marital status, income, education, disability, employment history, and any other information which the Friendship Centre/Delivery Site requires in order to deliver programmes and services safely and efficiently. Your personal information may be collected from time to time. Consent for the use of that personal information may be referred where its uses are obvious and it has been voluntarily provided.
Only necessary information will be collected about you. The Friendship Centre/Delivery Site will collect, use, and disclose information about you for the following purposes: - To enable the Friendship Centre/Delivery Site to contact you; - To ensure you are eligible for programmes and services; - To develop plans of care and practice case management of you file; - To ensure you are physically and mentally able to participate in programmes and services offered by the Friendship Centre/Delivery Site; - To provide specific information into a data collection system, specific to the programmes(s) in which you participate; and, - For anonymous statistical analysis of programmes and services.
The storage, retention and destruction of your personal information complies with the Friendship Centre/Delivery Site’s maintenance policy, applicable legislation and privacy protection protocols, to ensure its confidentiality. All staff at the Friendship Centre/Delivery Site are sworn to an Oath of Confidentiality.
Your information will only be shared upon your written consent, except the following: - For programmes reporting requirements, some personal information is sent to the Ontario Federation of Indian Friendship Centres, which may be transmitted in electronic form; - For studies, research, or reports on issues specific to the urban Indigenous peoples, with any of your identifiable information removed; and, - For the purposes of eliminating or reducing significant risk of serious bodily harm to any individual or group of peoples.
Your consent may be withdrawn at any time by notice to the Friendship Centre/Delivery Site or its Executive Director.
You may access your own personal information, or request corrections, through a written request to the Friendship Centre/Delivery Site or its Executive Director.
Your consent may be withdrawn at any time by notice to This consent form will serve for all Friendship Centre/Delivery Site programmes you access, with on programmes designated as your primary provider and your original consent kept in that programmes file.
I (“the Client”) have read and understood the preceding Notice and had it explained to me. I am aware how the Friendship Centre/Delivery Site will use my personal information. I am also aware of the steps taken by the Friendship Centre/Delivery Site to protect my information, when it is collected, used or disclosed, as well as how it will be stored and destroyed. I consent to the provisions of the preceding Notice.
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