En Route Registration Form

This form is intended for the use by community members to refer individuals and families to KIS En Route program, and also for individuals and families to self-refer themselves for services. The services are only available to refugees, immigrants and a limited number of temporary foreign workers, international students and citizens who face multiple barriers to their settlement. If they do not meet specific eligibility criteria they will not be considered for service with this program and will be referred to appropriate services. Meeting these minimum criteria does not guarantee services or immediate services.

Referring Agency Information

Name of the Referring Agency (if applicable):

Date of Referral:

Name of referring Individual or Agency Staff:

Contact phone number:

Position (if applicable):

Email address:

Information of intended service recipients:

First Name

Middle

Family/Surname (Last name)

Date of Birth

Address

City

State/Province

Zip/Postal

Country

Phone

Country of Origin

Date of arrival in Canada

First Language

Preferred Official Language

English

French

No. of Family Members:

Adults

Young Adult (19-25)

Youth (13-18)*

Children (under 12)

Immigration Status (Choose one)

Permanent Resident

Government-Assisted Refugee

Protected Person under IRPA S.95

Naturalized Canadian Citizen

Privately Sponsored Refugee

International Student

Temporary Foreign Worker

Individuals selected by Canada to become a permanent resident and are pending admissibility assessment by IRCC

Other (please specify):Other (please specify):

Other(s) (Please Specify):

Consent to Release Information: By signing below you, the referred individual, are indicating that you have given permission to the person (community or family member) to release this information to KIS for the sole purpose of determining your eligibility for En Route program. If you are referring yourself, your signature indicates your voluntary consent to release this information for the same purpose. This release will be in effect for two years from the date of signature.

Signature

Clear

Questions? Feel free to email,

Liza Ferris at [email protected]

Client Confidentiality: Kamloops Immigrant Services protects personal information by following the government’s privacy laws as outlined in the Personal Information Protection Act, Bill 38 https://www.leg.bc.ca/pages/bclass-legacy.aspx#/content/legacy/web/37th4th/3rd_read/gov38-3.htm

KIS En Route program
448 Tranquille Road, Kamloops BC V2B 3H2

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Registration Form

Referring Agency Information

Information of intended service recipients:

Indicate the issues/barriers to settlement the individual/family is facing by checking all appropriate boxes:

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En Route Registration Form

Achieve Program

Registration Form

Referring Agency Information

Information of intended service recipients:

Indicate the issues/barriers to settlement the individual/family is facing by checking all appropriate boxes:

QUICK LINKS

COME VISIT US!

Our Office Hours

Contact

Please be advised

Sign Up for our Newsletter

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