Adopt-a-Family Support Request Form

First Name

Last Name

Birthdate^*

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

Preferred Language

Street Address

City

State / Province

ZIP / Postal Code

Email Address^*

Phone^*

Adults in the Household

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

Adult #1 – Your Information (Applicant)

First Name

Surname

Birthdate^*

Relationship to you^*

Self

Adult #2

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #3

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #4

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #5

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #6

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #7

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #8

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #9

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #10

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #11

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #12

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #13

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Adult #14

First Name

Surname

Birthdate^*

Relationship to you^*

Select your relationship

Children in the Household

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

Child #1

First

Last

Birthdate^*

Child #2

First

Last

Birthdate^*

Child #3

First

Last

Birthdate^*

Child #4

First

Last

Birthdate^*

Child #5

First

Last

Birthdate^*

Child #6

First

Last

Birthdate^*

Child #7

First

Last

Birthdate^*

Child #8

First

Last

Birthdate^*

Child #9

First

Last

Birthdate^*

Child #10

First

Last

Birthdate^*

Child #11

First

Last

Birthdate^*

Child #12

First

Last

Birthdate^*

Child #13

First

Last

Birthdate^*

Child #14

First

Last

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

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

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

Accepted file types: jpg, png, pdf, jpeg
Max. file size: 20 MB.

Please note: you may not receive a notification that your supporting financial documentation upload was successful. Please upload your attachment as usual.

Examples of Proof of Income are Notice of Assessment OR recent pay stubs from all working parties in the household. Closer to Home does reserve the right to request proof of income at any time should you choose not to upload at this time.

If your family is selected and we are missing this documentation, you'll be asked to share it at a later date.

Security Note: These documents will only be used to verify income eligibility and will be kept strictly for the duration of the campaign. Once the campaign concludes, all uploaded files will be securely deleted. All information submitted through this form adheres to Closer to Home's Privacy Policy and will not be shared.

Anything else?

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

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Adopt-a-Family Support Request Form