Physical Activity Group Intake Form

For all programs, groups and services at Grand River Community Health Centre, we collect information about our group participants and clients. The info collected on this form will also help us to provide you with the best experience possible at GRCHC.

Please note, for physical activity groups we require emergency info from all clients.

Please indicate the name of the group/ program you are registering for:

First & Last Name:

Preferred Name:

Birth Date:

Address & Postal Code:

Phone #:

Email Address (GRCHC may contact you with group info):

Please provide the information for an emergency contact (Name, Phone Number, Relationship).

Social Information

Some social information is collected to help us better understand client needs and to improve our programs. If there is a question you would rather not answer, we provide a "prefer not to answer" option!

Gender:

Sexual Orientation:

What language do you speak at home?

What is your household composition?

Place of residence.

Were you born in Canada?

If NO, what country were you born in?

If NO, when did you arrive in Canada?

Are you currently...

What is your total household income before taxes last year?

How many people does this household income support?

What is your sense of belonging in our community?

Very Strong

Somewhat Strong

Somewhat Weak

Very Weak

Do not know

Prefer not to answer

What is your assessment of your own physical health?

Excellent

Very Good

Good

Fair

Poor

Do not know

Prefer not to answer

What is your assessment of your own mental health?

Excellent

Very Good

Good

Fair

Poor

Do not know

Prefer not to answer

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Physical Activity Group Intake Form

Social Information

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