Formulaire d'Inscription pour le Kit d'Hygiène Essentiel - Essential Hygiene Kit Registration Form

Basket of Basic Needs

Please fill in this form to receive a hygiene kit
About:
- This service is intended for newcomers, refugee claimants, and those without an official government status.
- This service is meant to supplement your regular purchases. It is not meant to replace it.
Frequency:
- Hygiene kits are distributed every Monday morning and require registration before hand.
Requirements:
- Please bring your own re-usable bags.
- For verficiation purposes, please bring a proof of name. This can be any form of identitifcation, such as your brown paper, or a letter addressed to you.
- Please be on time! Late arrivals may not be able to receive a hygiene basket and repeated missed appointments without notice may prevent your use of the service.
Limits:
- Hygiene baskets are available once per month per family.
We want to provide as much to as many people as possible. Please help us do so by being respectful to staff and volunteers.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Appartment

CityProvince

Postal Code
Country of Origin
Date you arrived to Canada

DayMonthYear
Date
What is your legal status?
What languages do you speak? Please select all that apply

Other
What gender do you identify as?
What is your family situation?
Date of birth

DayMonthYear
Date
Who is this hygiene request for:
How many people are in your household?
Please list their ages:
Do you have a child who requires diapers? Please select their size.
Please select your kit pick-up time:
Don't see any availabilities? Please check again on the last Thursday of this month.

Registration opens for one month at a time, beginning on the last Thursday of the preceding month. For example, registration for April will open on March 26th.

Consent to Disclose Personal Information

By checking the box below, I acknowledge and consent to the following:
- I voluntarily provide my personal information, including name, contact details, and other relevant data, to The Refugee Centre for the purpose of facilitating the provision of services and any related activities.
- My personal information will be used internally by The Refugee Centre and may be shared with third-party organizations only with my explicit consent, which will be requested via a separate consent form.
- My personal information will be retained for the duration necessary to fulfill these purposes and in accordance with Quebec’s privacy laws, including the Act Respecting the Protection of Personal Information in the Private Sector (Loi sur la protection des renseignements personnels dans le secteur privé). I understand that I have the right to access, update, or correct my personal information at any time.
- My personal information will be securely stored and handled in accordance with industry standards.
- I may withdraw my consent at any time by notifying The Refugee Centre, though I understand that doing so may affect my ability to participate in the program or receive services.
- For any questions or concerns regarding my personal information or to exercise my privacy rights, I can contact the Centre’s Privacy Officer at privacy.confidentialite@therefugeecentre.org
Please Confirm below
Your country of origin (do not delete)
What is this about?
Should be Empty:

Basket of Basic Needs