Pencil cost Operation

Informations

Total number of people*

Number of beneficiary's children*

Full name*

Phone home*

Cell phone

Email

Spouse's full name

Address*

Appartment

Postal code*

Town*

District*

Habitation

Spoken languages*

English

French

Other

Native country

If other, specify :

Contact name

Relationship with the person

Contact phone

Reference

Monthly income

Without income*

Income expectation*

Canada Child Benefits

Quebec Child Benefits

Job assistance

Employment Insurance

CNESST

Disability/widower

Alimony

Additional pension

Loan and/or grant

Solidarity credit

Insurance income

Pension income

Investment income

SAAQ

Salary

Other

Monthly expenses

Insurance

Cable/Phone/Internet

Heating

Electricite

Rent

Mortgage

Coop/HLM

Debts

Care expenses

Medical fees

Transportation costs

Alimony

Other

Child/Children

(Ages 4 to 17 primary or secondary level only) ** Enter the school year of your child in September 2022 **

First name	Class	Special class	Name of the school	Level	School service center	Actions

There are no entries.

PRIVACY OF PERSONAL INFORMATION *

The Centre de bénévolat et moisson Laval is committed to ensuring the confidentiality of your personal information. Do you authorize the Centre de bénévolat et moisson Laval to keep your data for reference purposes for another program or for a future request for support?

I consent

I refuse

Do you participate in a program concerning assistance with school entry elsewhere?

Yes

Have you participated in our program before?

Yes

If so, which years?