Adult Grief & Loss Support Group

Community Links Data Collection *

• All information you share with Community Links is kept confidential within the agency. Staff members meet on occasion to exchange ideas and suggestions on how to better support the individuals and families we are working with. • Personal information is being collected for Community Links and will be used to enhance, strengthen, and stabilize family and community life. It is stored on the Community Links internal server as well as on the Penelope database. All information is protected by the privacy provisions of the Freedom of Information and Protection of Privacy Act. All employees are responsible for ensuring ethical and professional usage of Penelope and excel systems.

I have read & understand the Community Links Data Collection statements.

Legal Name *

First Name

Last Name

Preferred Name

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Were you born in Canada? *

Yes

No

Are you an Indigenous person, that is, First Nations, Metis or Inuit? *

Yes

No

Are you Francophone? *

Yes

No

Emergency Contact *

First Name

Last Name

Emergency Phone *

(###)

###

####

Would you like to receive email notifications of our programs and events? *

Yes

No