Test

    Name                                                                                           Age

    Address

    Phone Number                                                     Email

    Number of Children (If more than 3, list 3 youngest below



    Child 1

    Infant to Toddler3-6 Years7-13 Years14-17 Years18-25 Years

    Child 2

    Infant to Toddler3-6 Years7-13 Years14-17 Years18-25 Years

    Child 3

    Infant to Toddler3-6 Years7-13 Years14-17 Years18-25 Years

    Annual Household Income



    Source of Income

    Ontario Works (OW)EICERBWSIBEmploymentOSAPChild SupportInvestment



    I hereby grant Community Alliance for Support and Empowerment (C.A.S.E.) permission to use photographs for the purposes of web-based publications, print advertisements and organization bulletins and affirm that such release to C.A.S.E does not constitute any form of compensation, including royalties arising from the photographs, to my benefit.


    I hereby hold harmless, release, and forever discharge Community Alliance for Support and Empowerment and it's affiliates, including third parities from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.



    VERIFICATION (Please attach a copy of your ID)


    Upload your File


    Please note that your ID must match name and address above



    Signature: I hereby declare all information disclosed in this form to be true.