Jordan’s Principle On-Line Service Request Form

Jordan's Principle On-Line Request For Services Form

PLEASE LET US KNOW IF YOU NEED HELP WITH FILLING OUT THIS FORM. We can be contacted toll free at 1-888 - 815 -5511 or 250-381-7303 (Victoria Capital Region)

Please provide the child's full name as it appears on their government issued identification. You can also include their traditional name, if applicable. Please complete this and the additional required information for each child you are requesting services for. If you are requesting services for more than 3 children, please contact our office.
MM slash DD slash YYYY
Please provide the child's date of birth in Month/Day/Year format.
Child 1 - Gender(Required)
Please select the gender of child 1.
Does Child 1 have a disability(s)?(Required)
Please indicate if Child 1 has a disability(s)
Child 1 - Indigenous Ancestry/Status(Required)
Please select the Indigenous Ancestry of Child 1.
Please provide the name of the parent/legal guardian requesting services for child 1. If there are two parents/guardians involved with the child who must be informed of this request, please enter the name and required information of the second parent/guardian in section 2 below.
Please provide a telephone number you can be reached at in relation to this request.
Please provide an email address you can be reached at in relation to this request.
Parent/Guardian 1 - Mailing Address(Required)
Please provide the mailing address of child 1.
Where does Child 1 Reside?(Required)
Please indicate if the provided mailing address is within a First Nation or non-First Nation community.
Please provide a brief description of the supports you require and/or the nature of Child 1's disability, if applicable.

Section 2

Parent/Guardian 2/ Information (if applicable)

Parent/Guardian 2 - Mailing Address
Privacy/Consent(Required)