New Application

What program/services are you registering for? (required)

How did you hear about us? (required)

First Name (As shown on immigration document) (required)

Middle Name (As shown on immigration document)

Last Name (As shown on immigration document) (required)

Birthdate (MM/DD/YEAR) (required)

Preferred Name

Gender (required)

Pronoun you identify with

Please create a password for future log ins to your IRSA account profile (required)

Immigration Status (required)

Nationality (required)

Marital Status

Residential Address (example: 6960 Mumford Road) (required)

Unit/Apt if applicable

City/Town (required)

Province (required)

Postal Code (required)

Country of Origin (required)

Email (required)

Cell Phone

Home Phone

UCI # (required)

Intake meetings are short meetings where we quickly assess your needs and redirect you to the appropriate departments. These meetings take between 30 minutes to 1 hour and are normally held virtually. If you don't feel comfortable enough having online meetings, we can also accommodate in-person meetings (required)

Will you be initially meeting with us individual or with your family? (required)

Date of Entry to Canada (mm/dd/year), if applicable

Date of Entry to Prince Edward Island (mm/dd/year), if applicable

Are you able to speak, understand and read English? If not, what language would you like to use at your appointment (required)

Primary Language (required)

Other Language

Preferred Official Language (required)

Where are you settling in Prince Edward Island

Consent to collect, use, and share personal information

Immigrant & Refugee Services Association Prince Edward Island (IRSA PEI) is an organization that welcomes immigrants and delivers settlement and integration programs and services. We can provide most services for free because we receive funding from the Canadian and Prince Edward Island governments (we are a registered charity and a non-profit society).

In Canada, organizations are required to obtain consent from individuals to collect, use or share personal information (under the Personal Information Protection and Electronic Documents Act (PIPEDA) (www.priv.gc.ca/leg_c/leg_c_p_e.asp). This means that organizations need to provide clear information to individuals explaining what they are doing with their personal information. When you consent to something, it means that: 1) you permit or give your permission, and 2) you voluntarily agree.

To support you, IRSA PEI must share some of your personal information with our funders, and when we refer you to services and program within IRSA PEI and other organizations.IRSA PEI Intake Services collects and uses your personal information to:

• Create an electronic file to hold your information
• Create a settlement plan
• Refer you to services that you select within IRSA PEI or the community
• Contact you to see if you need further support
• Provide information and promote programs and services that may be of interest to you
• Meet our funder obligations to provide services and complete reporting. Please note: Immigration, Refugees and Citizenship Canada (IRCC) periodically contacts individuals to get feedback on the settlement services they fund. Your consent allows IRCC to contact you. If you do not consent to this, then you cannot receive our IRCC-funded services.

Please note:

• You may be asked to sign other program-specific consent forms depending on the services that you want or need.
•You may be asked to provide your Social Insurance Number (SIN) in order to accessprovincially-funded programs (including Employment, Language and Business services). Ifyou do not provide your Social Insurance Number, then staff cannot offer those services to you.
•You may refuse to consent or withdraw your consent at any time (allowing 5 business daysfor IRSA PEI to process). However, if we do not have your consent, then we may not be ableto provide you with certain services.
•IRSA PEI does not need your consent to share your personal information when we must bylaw, such as situations of abuse, harm to yourself, or harm to others.
•You can find out more about IRSA PEI Client Privacy Policy by going to the “About” tab on our website (https://www.irsapei.ca/en/background-work-and-activities).If you have questions about this consent form or about how your information may be used, you are welcome to discuss this with your Intake Counsellor. If you agree to allow IRSA’ Intake Services to use and share your information as listed above, please sign your name and write the date below. If you are the parent or guardian of a child who is younger than 19 years of age, please list their names to show that you agree that their information can be shared as outlined above.

Consent to collect, Use, and share personal information.

if you would like to change your consent please email intakes@irsapei.ca (required)

- I hereby confirm that the information provided
by me on this registration form is current and accurate (required)

- Today's Date (mm/dd/year) (required)