Panier de Noël Form

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Panier de Noël 2026

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First Name *

Last Name *

Date de naissance *

Votre Sexe? *

Masculin
Féminin
Other

Phone Number *

Email *

Preferred communication language *

French
English

Are you covered by the low income threshold standard? Check the box that corresponds to the range of your annual income, based on the size of your family *

1 personne en famille? Revenu familial après impôt inférieur ou égal à 25 909$
2 personnes en famille? Revenu familial après impôt inférieur ou égal à 31 533$
3 personnes en famille? Revenu familial après impôt inférieur ou égal à 39 265$
4 personnes en famille? Revenu familial après impôt inférieur ou égal à 48 966$
5 personnes en famille? Revenu familial après impôt inférieur ou égal à 55 781$
6 personnes en famille? Revenu familial après impôt inférieur ou égal à 61 862$
7 personnes et plus en famille? Revenu familial après impôt inférieur ou égal à 67 944$

Is the client's address a co-op or apartment building? *

If yes, please enter the alarm or bell number here:

Is it a shelter or a shared apartment? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Does the client have a spouse or partner? *

If yes, please enter their email

Last Name

If yes, please enter their phone number

Number of Kids (0 to 17 years old) *

Please enter the name(s), gender(s) and age(s) of all children in the household

Number of adults (18 to 54 years) *

Please enter the name(s), gender(s) and age(ies) of all seniors in the household: (If applicable – Include the client listed in the primary information section):

téléphone et ou

Total number of seniors (55 years and over) *

Please enter the name(s), gender(s) and age(ies) of all seniors in the household: (If applicable – Include the client listed in the primary information section):

Other information:

Would you like to be contacted for other services offered by CICAN? *

By filling out this form, you agree to share your data with us. All data collected will be used only for the purpose of this booking and will not be shared with any third party unless you explicitly authorize it.

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