LRCA Food Bank Registration FormThank you for filling out this form in advance.On your first visit, please be prepared to show Care Cards for each family member. Proof of address will also be needed.Food Bank Registration FormPlease enable JavaScript in your browser to complete this form.First VisitDate of first visit2nd VisitDate of 2nd visitCard Member Name *FirstLastGender *MaleFemaleOtherDate of Birth *Your BirthdateStreet AddressYour addressPostal Code *Phone NumberEmailMarital Status *SingleMarriedCommon-LawDivorcedSeparatedWidowedSpouse/Partner NameFirstLastSpouse Date of BirthSpouse GenderMaleFemaleOtherDEPENDENTS (live with you and are under 18)FirstLastDependent 1 Date of BirthDependent 2FirstLastDependent 2 Date of BirthDependent 3FirstLastDependent 3 Date of BirthDependent 4FirstLastDependent 4 Date of Birth Dependent 5FirstLastDependent 5 Date of BirthDependent 6FirstLastDependent 6 Date of BirthAdditional dependentsInclude Full Name and Date of BirthHow did you hear about the LRCA Food Bank?How long have you lived in Ladysmith?Less than 6 months6 months to 1 year1 year to 5 years5 to 10 yearsOver 10 yearsI am new to Canada *YesNoIf yes, when did you arrive?I can get to and from the food bank without help *YesNoI can come to the food bank regularly on Tuesday evening or Wednesday morning *YesNoIf no, why not?If no, what day and time could you come to the food bank regularly? I am disabled *YesNoI am a Post-Secondary student *YesNoI amFirst NationMetisInuitOtherMy home is *Band ownedOn the street/in the shelterSupported LivingWith family or friendsRentalI own my homeMain source of income *Full time workPart time workSeasonal employmentSocial assistanceStrike payMedical EIEIWCBOld age/Canada pensionNo incomeSpouse main source of incomeFull time workPart time workSeasonal employmentSocial assistanceStrike payMedical EIEIWCBOld age/Canada pensionNo incomeSubmit