Jordan’s Principle On-Line Service Request Form

Child 1 - Full Legal Name(Required)

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.

Child 1 - Date of Birth (MM/DD/YY)(Required)

Please provide the child's date of birth in Month/Day/Year format.

Child 1 - Gender(Required)

Boy

Girl

2 Spirited

Transgender Boy

Transgender Girl

Non-Binary/Non-Conforming

Prefer not to answer

Please select the gender of child 1.

Does Child 1 have a disability(s)?(Required)

Yes

Uncertain

Prefer not to answer

Please indicate if Child 1 has a disability(s)

Child 1 - Indigenous Ancestry/Status(Required)

First Nation Status

First Nation Non-Status

Non-Status Child of Status First Nation Parent

In the process of applying for First Nation Status

Inuit Status

Child 1 is not Indigenous

Please select the Indigenous Ancestry of Child 1.

Please provide one parent’s Status/Registration Number if child 1 is not registered or is currently in the process of being registered.(Required)

Please provide the name associated with Status/Registration Number noted above.(Required)

Parent/Guardian 1 - Legal Name(Required)

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.

Parent/Guardian 1 - Contact Telephone Number(Required)

Please provide a telephone number you can be reached at in relation to this request.

Parent/Guardian 1 - Contact Email (If available)

Please provide an email address you can be reached at in relation to this request.

Parent/Guardian 1 - Mailing Address(Required)

Street Address Address Line 2 City Province Postal Code

Please provide the mailing address of child 1.

Where does Child 1 Reside?(Required)

First Nation Community (On-Reserve)

Non-First Nation Community

Please indicate if the provided mailing address is within a First Nation or non-First Nation community.

Nature of Jordan's Principle Service Request(Required)

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 - Legal Name

Parent/Guardian 2 - Contact Telephone Number

Parent/Guardian 2 - Contact Email

Parent/Guardian 2 - Mailing Address

Street Address Address Line 2 City Province Postal Code

Indigenous Disability Canada / B.C. Aboriginal Network on Disability Society (IDC/BCANDS)

British Columbia Aboriginal Network on Disability Society (BCANDS)

Jordan's Principle On-Line Request For Services Form

Section 2

Parent/Guardian 2/ Information (if applicable)