Clinics and Classes for Parents, Caregivers and Children

Parent / Guardian Information

* First Name

* Last Name

* Sex Male
Female
Prefer not to answer

* Date of Birth Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031 Year 2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904

* Expected Due Date

---

Contact Information

* Phone xxx xxx xxxx

Niagara Region can text class updates to this number

* Email

* Address
Start typing and select from the dropdown list provided

* Postal Code

---

Demographic Information

We are collecting social and demographic information from those who register for our programs. We want to understand who we serve, and what needs our clients have. We will use this information to improve our programs for Niagara residents.

Answering these questions is voluntary. The information will not be shared with anyone outside of Niagara Region Public Health. Only non-identifiable summarized data will be used in reporting.

Niagara Region's Personal Health Information Practices

What is your highest education level? Select a level... Did not complete high school Completed high school Some post-secondary education Bachelor's degree, diploma or certificate (including trades) Advanced degree (above Bachelor's)

What language do you speak most often at home?
Start typing and select from the dropdown list provided

Do you identify as an Indigenous person? Select one... Yes No

What was your total family income before taxes last year? Select a range... $0 - $19,999 $20,000 - $24,999 $25,000 - $29,999 $30,000 - $34,999 $35,000 - $39,999 $40,000 - $59,999 $60,000 - $79,999 $80,000 or more Do not know

How many people does this income support?

How did you hear about us? Select one... Child care centres Community programs (EarlyONs, YMCA, sports programs, etc.) Doctor's office or healthcare centres Friends/family Google search Niagara Region Public Health website Social media (podcasts, YouTube, Instagram, Facebook, etc.) Other

Do you require any accommodations due to a disability?

---

May we contact you about additional free services offered by Niagara Parents and Niagara Region Public Health?

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.