Adopt-a-Family Support Request Form

Birthdate^*

*New Canadian is a recent immigrant to Canada, but has not yet obtained Canadian Citizenship.

Preferred Language

Email Address^*

Phone^*

Adults in the Household

How many individuals, over 18, live in the household?^*

Adult #1 – Your Information (Applicant)

Birthdate^*

Relationship to you^*

Self

Adult #2

Birthdate^*

Relationship to you^*

Select your relationship

Adult #3

Birthdate^*

Relationship to you^*

Select your relationship

Adult #4

Birthdate^*

Relationship to you^*

Select your relationship

Adult #5

Birthdate^*

Relationship to you^*

Select your relationship

Adult #6

Birthdate^*

Relationship to you^*

Select your relationship

Adult #7

Birthdate^*

Relationship to you^*

Select your relationship

Adult #8

Birthdate^*

Relationship to you^*

Select your relationship

Adult #9

Birthdate^*

Relationship to you^*

Select your relationship

Adult #10

Birthdate^*

Relationship to you^*

Select your relationship

Adult #11

Birthdate^*

Relationship to you^*

Select your relationship

Adult #12

Birthdate^*

Relationship to you^*

Select your relationship

Adult #13

Birthdate^*

Relationship to you^*

Select your relationship

Adult #14

Birthdate^*

Relationship to you^*

Select your relationship

Children in the Household

How many individuals, under 18, live in the household?^*

Child #1

Birthdate^*

Child #2

Birthdate^*

Child #3

Birthdate^*

Child #4

Birthdate^*

Child #5

Birthdate^*

Child #6

Birthdate^*

Child #7

Birthdate^*

Child #8

Birthdate^*

Child #9

Birthdate^*

Child #10

Birthdate^*

Child #11

Birthdate^*

Child #12

Birthdate^*

Child #13

Birthdate^*

Child #14

Birthdate^*

Additional Information

What’s the last year been like for your family?

Sharing your story helps us advocate for the resources our community needs. We may share a version of your experience with our supporters, but all identifying details, including full names and contact information, are removed and altered to ensure your information remains confidential.

Is anyone pregnant in the household?^*

Yes

No

In the last year, have any of the following circumstances caused a loss in household income (select all that apply)^*

Job loss

Loss of primary care-giver

Significant medical emergency/critical illness

Change of status (immigration)

Housing status change (loss of housing)

None of the above

Are you currently registered with OR receiving support from any of the following programs (select all that apply)

Assured Income for Severely Handicapped benefits (AISH)

Alberta Works: Income subsidy/support

Alberta Works: Learners

Alberta Works: Alberta Health Benefit

Resettlement Assistance Program

City of Calgary Fair Entry Program

Housing Subsidy Program

None

Other subsidy program not listed

Other subsidy program not listed^*

Have you ever received services from Closer to Home in the past?^*

Yes

No

Closer to Home services (select any that apply)^*

Adopt-a-Family

Summer in the City

Women’s Group

Family Matters

Home Visitation

Other (open field)

Other Closer to Home service/s^*

Supporting financial documentation

No file chosen

Anything else?

Do you feel like there are any other details surrounding your request for support that Closer to Home should be aware of?

Adopt-a-Family Support Request Form