Family Literacy Program Registration Form

Family Literacy Program

Sessions are drop-in Monday to Friday 10:30am - 12:30pm SUCCESS Surrey Main site at: #100 – 15117 101 Avenue, Surrey
Priority is given to Permanent Residents, Convention Refugees, Protected Persons, and Live-in Caregivers.
Parent's Legal Name*

First NameLast Name
Parent's Phone Number*
Please enter a valid phone number.
Parent's Email *
example@example.com
Parent's Date of Birth*

MonthDayYear
Date
Please provide your Permanent Resident Card (PR Card) ID# or Immigration document number issued by IRCC.*
(FOSS/GOMS Client ID, Temporary Resident, Minister's Permit Number, IMM5292, IMM5509, IMM1000, CUAET#)
Immigration Status*

Permanent ResidentProtected PersonLive-In CaregiverConvention Refugee
Child #1 Legal Name*

First NameLast Name
Child #1 Date of Birth*

MonthDayYear
Date
Child #2 Legal Name

First NameLast Name
Child #2 Date of Birth

MonthDayYear
Date
Parent's Emergency Contact First and Last Name*
Parent's Emergency Contact Phone Number *
Please enter a valid phone number.
Personal information collected and maintained by the S.U.C.C.E.S.S. Immigrant Settlement & Integration Program is subject to the provisions of the applicable federal, provincial or territorial privacy and access to information legislation or the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Personal Information Protection Act (PIPA).Therefore, information shared in-person, by phone, email, or online will be kept confidential in accordance with this legislation and will be used only to assist staff in providing service, determining service eligibility and generate anonymous statistics. Confidentiality of the information can only be breached when: required by law or by an order of court; there is reasonable ground to believe that such release will prevent harm; it is necessary to disclose the information to the personnel of S.U.C.C.E.S.S. or accreditation agencies that are authorized to receive such information in the course of their duties. All records are confidential and retained in a secure and protected environment. S.U.C.C.E.S.S. is required to record information pertaining to personal and service information on a federal Immigration, Refugees and Citizenship Canada database that monitors service outcomes.*

I agree to the above stated use of my personal information.
I would like to be contacted by Immigrant Settlement and Integration Program (ISIP) staff to receive online, email or phone services and learn about upcoming settlement workshops, courses, or events for newcomers. If I no longer wish to be contacted by S.U.C.C.E.S.S. staff, I may request to be removed from any S.U.C.C.E.S.S. e-mail lists at any time.*

I give consentI do not give consent
If I require service (eg. workshops, webinars, activities) in another ISIP region (Burnaby/New-Westminster, Richmond, Surrey/Fraser Valley, Tri-Cities, Vancouver, & Fort St. John), I agree to give consent to ISIP staff to release my information to the ISIP staff who will serve me in that region.*

I give consentI do not give consent
Should be Empty: