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Support for seniors - Healthy aging
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First Name
*
Last Name
*
Phone Number
*
Email
*
Referred by:
Gender:
*
F
M
Other
Native country:
*
Status:
*
Canadian Citizen
Permanent resident
Refugee/Protected person
Other
If other, please specify
Preferred language of communication
French
English
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Age
*
50-65
65 and over
In which official language would you prefer to be served?
*
French
English
In which form of activities would you prefer to be served?
*
Present in person
Online
Please note that some activities require your presence in person
Check all the boxes of services you wish to participate in
Information on the Canadian health system.
Group and individual counseling aimed at well-being and mental health
Twinning activities
Discovery of Canadian history and culture
French converstion circles
digital support
Short-term group and individual counseling
Be referred to other services offered by our partners
Would you like to be contacted for other services offered by CICAN?
*
Yes
No
Other information:
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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Du nouveau! CICAN lance son nouveau programme - Vieillir en santé- financé par IRCC
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