FOR PROGRAM STAFF ONLY:

Immigrant Youth Centre| Activity Registration

New ISAP client at initial intake □
Completed initial Needs Assessment □
.PERSONAL INFORMATION. .SETTLEMENT INFORMATION.
Staff: ___ ________
2015-november-11
Name: Sherzay Date of Entry into Canada:
yyyy-mm-dd
LAST NAME
IF APPLICABLE:
Zahoor How long have you been in Canada?: Fee: □Cash □Cheque (# )
GIVEN NAME (Name on Official Government Documents) 5
__________Years 5
and ___________ Months Receipt No.: ________ _
Zahoor
OTHER NAME (English names, Preferred names, etc)
Current immigration/ citizenship status (√ one): Date: Staff Signature:

Gender (√): □Male

✔
□Female Client ID: ___
□ Permanent Resident/ Conventional Refugee
✔

247 knapton drive Document No.:

.DISCLAIMER.
Address: 8 digit “ID No”. or T********
STREET / APARTMENT NUMBER &

Category (found on back side of card): 1. Participants should take care of their own safety. CICS-
newmarket l3x 3b7
IYC is not liable for any personal injury and/or
CITY POSTAL CODE
4372218164 □ Citizen loss/damage of personal property.
4372218164
Phone #: 2. For refund procedures, please refer to the agency’s
HOME WORK/CELL Document No.:
Official Government Issued Photo ID# refund policy.
khanzohoor77@gmail.com
E-mail: _____________________________________
□ Refugee Claimant
Date of Birth: 2003-11-1 Document No.: .CONSENT (√).
yyyy-mm-dd IMM 1442 Client ID #
□ I hereby give permission for photos or videos to be
✔

(if applicable) □ VISA student taken of me/my child/ individual under my care in
Dr John M Denison
Name of School: _____________________________ Document No.: CICS-IYC activities for the purpose of publishing them
Grade: ____
12 VISA Permit’s Client ID# on CICS-IYC printed materials or other media in
promotion.
Place of Origin (√): □ Other ____________________________________ □ I hereby give permission to CICS-IYC to contact me
✔

□ Canada □ China □ HK SAR Document No.: and deliver agency information to my email address
Official Government Issued Photo ID#
□ India □ Iran □ Iraq and understand I could withdraw my consent at any
□ Korea □ Pakistan □ Russia Parent/ Guardian: time.
□ Sri Lanka □ Taiwan □ Vietnam Name & relationship mansoor Sherzay
□✔
Other: Afghanistan Contact No. 6472898220 □ I hereby give consent for myself, my child, or the
✔

First Language, please check only one (√): E-mail: __________________________________

mansoorshirzay@yahoo.com individual under my care to participate in any
□ English □ French □ Arabic activities/programs organized and held by CICS-IYC,
Emergency contact: and to receive emergency treatment if necessary and
□ Bengali □ Cantonese □ Farsi ✔
Name mansoor sherzay release CICS-IYC from all claims arising from any
□ Hindi □ Korean □ Mandarin Relationship brother accident, loss or injuries which are caused by or
□ Punjabi □ Russian □ Spanish
Contact No. 6472898220 arising from such participation and/or treatment.
□ Tamil □ Urdu
□ Other: Signature of applicant/minor’s parent or guardian:
How did you hear about the IYC? (√):
□ Friends/ Family □ IYC Website
OHIP #: ________________________________
□ Newspaper □ School □ ✔
IYC Flyer
 Check if insured through school (VISA student) 2021-june-29
□ Others (please specify)________________________ Date: ________
(Apr/15)