» REGISTRATION FORM

Please note that the form must be completed correctly for faster processing. The program is open to women; children are not admitted. *

Okay

First and last name

Date of birth

Phone number

Roaming time

Civil status

What is your legal status in Canada?

Communication language:

Name of the referring organization:

Name of the referent speaker:

We request the ongoing involvement of the caseworker throughout the follow-up process.

Number of months follow-up by a caseworker from the referring organization

SAINT-ANDRÉ: A Rooming house with 20 rooms with private bathrooms. The kitchen facilities and living rooms are in common areas. The building has many stairs and is not adapted for participants with reduced mobility. A team of caseworkers on site 24/7. DE CHAMPLAIN: A residence of 26 studios with a private bathroom and private kitchen. 4 studios adapted for participants with reduced mobility, but not accessible to participants with a wheelchair. On-site case worker, Monday to Friday, on a flexible schedule.

Okay

Source of income:

*By filling out this form, you agree to participate in our trust program.

Do you have a debt ?

Yes
No

If so, how much is the debt?

If so, name them:

Do you already have a home?

Yes
No

If yes, is your name on the lease? *

Yes
No

Have you ever been evicted from a subsidized apartment?

Yes
No

Do you have a record at the Régie du logement?

Yes
No

If yes, why?

Have you lived in the greater Montreal area in the past year?

Yes
No

(Section to be completed by the caseworker) Comments on the client’s current situation

If the client does not currently have revenue it is important to help them with this prior to referring them to the housing department. Send it to the following email address: residences@chezdoris.org

Name of the caseworker

Role

Organization

Phone number of the caseworker

Email address of the caseworker

I authorize the person and/or organization Chez Doris to exchange personal information about me with the person named above regarding the following matter(s)

I accept

Participant signature

Date

Caseworker signature

Date