Membership Form Company Information on parent 1 (father or mother) B-CITI Number Please register in order to obtain your B-CITI: Create a b-citi account Family name * First name * Birth date * Gender * F M Adress * App number City * Zip code * Cell number * Home number Email Status in Canada Citizen Permanent resident Refugee Foreign student Other Spoken Languages English French Other Education Level High school Trade school College University Other Would you like to receive our monthly newsletter? Yes No Would you like to volunteer at our organization? Yes No Information on parent 2 (father or mother) B-CITI Number Family name First name Birth date Gender F M Is your address different than parent 1? Yes No Cell phone number Home phone Email Status in Canada Citizen Permanent Resident Refugee Foreign Student Other Spoken languages English French Other Education Level High School Trade school College University Other Would you like to receive our monthly newsletter? Yes No Would you like to volunteer at our organization? Yes No Information regarding your children How many children do you have ? 1 2 3 4 5 Information on 1st child Family Name First Name Birth date Gender F M Birth order (1=Oldest) Allergies ? People authorized to pick up your child (when required) Do you have people other than the parents that you would like to add as authorized to retrieve your child? No Yes Activities and / or services you are receiving : Drop Off or other respite Parent-baby activity (5 senses, ..) AMorning parent-child activities for children 2 to 4 years (Let’s move, ...) Afternoon parent-child activities for children 3 to 5 years (Arts & Crafts, Croques-Notes,...) Evening parent-child activities for children aged 5 to 12 years (Busting stress, yoga,...) Adult Activities (Coffee Talk, Fathers,...) Social Activities (Holidays / Special events,..) Tax clinicTax clinic Ministerial requirements For parents who are registering for the Drop-Off center, we need to know why you need to use the centre. Thank you. Needs of the parents Respite Participating at an activity at la MFB Other ? Authorization Membership: by checking off yes, I become a member of La Maison de la famille de Brossard Yes Photographs Do you authorize La Maison de la Famille de Brossard to take photos of your family that will be used only internally (transmitted only to people present during the activity being photographed, to parents and employees; we are not responsible for the possible subsequent diffusion by parents). Yes No Do you authorize La Maison de la Famille de Brossard to use and/or diffuse (on web site, Facebook, etc…) photos of your family in order for us to promote our organization? No photo will be sold or given to third parties. Yes No Code of Ethics I commit to adhering to the Code of Ethics of La Maison de la famille de Brossard in my role as participant of this organization (respect, professionalism, confidentiality, integrity) Yes No
