Member Registration - Burnaby Neighbourhood House

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Registration Form

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Full Name *

Name *

First

Last

Username *

Email *

Password *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Individual/Family?

Single: $5
Family: Have up to 5 members for $10 only

Family ID

Number of people in your household you want to sign up (including yourself) *

0 - 5. Use 0 if you are joining an existing member's family. (All household members will need to provide proof that they live at the same address)

Family member #2 full name *

Family member #3 full name *

Family member #4 full name *

Family member #5 full name *

How did you hear about BNH?

Are you a BNH volunteer?

Home of type

Programs you are interested in?

Early Years
Preschool
School Age
Youth
Family
Adult
Community
Senior
Newcomers

Are you in the Senior's Program (55+)? *

Which Senior's Program are you interested in?

Seniors Connection
TAPS
Meals on Wheels
Frozen Meals
Online Grocery Shopping
Seniors Transportation
Information & Referral
Forms Filling
Peer & Caregiver Support
Community Connection

Are you a Social Connections participant?

Monday Soup and Bun
Wednesday Drop in
Friday Lunch

Are you a TAPS (Day Program) participant? *

Which TAPS activites are you participating in?

Arts
Day Program
Information Resources
Physical Activity
Social Services
Technology
One-to-one Check ins

Are you a part of the Community Connector (Social Prescribing) program? *

What's the support service are you receiving from our Community Connector?

Assessment/triaging
Co-creation of wellness plan
Follow-up/check in
Health system navigation

Are you a Better at Home participant? *

Are you currently receiving Public Home Support? *

What type of Public Home Support are you receiving?

Veteran Affairs
Health Authority/Health Support Services
Other

Other:

Which Better at Home programs are you registered to / interested in?

Senior Shopping
Frozen Meals
Light Housekeeping
Senior Transportation

Better At Home Subsidy Level

Would you like to register to the Better at Home program?

Do you need help completing any of these forms through the Information & Referral program?

Canadian Pension Plan
Old Age Security
Guaranteed Income Suplement
Housing Registry
SAFER
Provincial Bus Pass
Canadian Dental Care Plan
Health Connect Registry

Are you a QUEST+ participant? *

Which QUEST+ activities are you participating in?

Cafe
Advisory Commitee
On-on-One Support

Are you in the Caregiver program? *

Years in the Caregiver role *

Which Caregiver program activities are you participating in?

Individual: 1 On 1 Check In
Individual: Information & Referrals
Individual: Caregiver Navigation
Group: Education & Workshop
Group: Group Activities
Group: Special Events
Group: Working
Group: Chinese
Group: Farsi
Group: Spanish

Living Arrangement

Age Range

Gender

Primary Language

American Sign Language (ASL)
Arabic
Cantonese
English
French
Farsi/Persian
German
Hindi
Indigenous Languages
Japanese
Korean
Mandarin
Portuguese
Punjabi
Russian
Spanish
Tagalog/Filipino
Ukrainian
Vietnamese
Other
Unknown

Primary Language (Other ) *

Indigenous Peoples

Indigenous First Nations
Indigenous Inuit
Indigenous Metis

Indigenous Peoples - Residential Context

Living on Reserve
Living off Reserve/Away from Home
Unknown

Ethic Origin

Black
East Asian (e.g. Chinese, Japanese, Korean)
Latin/Central/South American
South Asian
Southeast Asian (e.g. Vietnamese, Filipino)
West Asian/Middle Eastern (e.g. Iranian, Afghan)
White
Prefer not to disclose
Other
Unknown

Ethic Origin (Other) *

Relationship to Care Recipient

Relationship to Care Recipient (Other) *

Activities of Daily Living

Mobility in bed
Transfer
Mobility in home
Mobility outside of home
Dressing
Eating
Toilet Use
Bladder/bowel care
Personal Hygiene
Bathing
Other

Activities of Daily Living (Other) *

Instrumental Activities of Daily Living

Meal preparation
Housework
Managing finances
Managing medications
Transportation
Substance use management
Other

Instrumental Activities of Daily Living (Other) *

Photo Consent *

I hereby give my permission to Burnaby Neighbourhood House to use photos of me/my family in BNH promotional material (e.g. newsletter). I grant BNH permission to use and publicize photographs of myself and/or the minor family on this form in publication

If you’d like to support our work, please consider making a small donation using the link below. Thank you for your kindness!

BNH South House

South Burnaby

#100 – 4460 Beresford St,
Burnaby, BC V5H 0B8

(604) 431-0400
receptiona@burnabynh.ca

Monday – Friday | 9:00am – 5:00pm

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BNH North House

North Burnaby

4908 Hastings St,
Burnaby, BC V5B 1P6

(604) 294-5444
northinfo@burnabynh.ca

Monday – Friday | 9:30am – 4:30pm

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BNH Brentwood House

North Burnaby

2055 Rosser Ave, Burnaby, BC V5C 0H1

(604) 299-5778 | (604) 299-5754
info@bbyservices.ca | info@burnabymeals.ca

Monday – Friday | 9:00am – 4:30pm

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Burnaby Neighbourhood House is a community driven and community funded agency located on the unceded territoriesof the Tsleil-Wauthuth (sə ̓l ̓lil ̓w ̓w ətaʔɬ), Kwikwetlem (kʷikʷə ̓ƛ ̓ƛ əm),Squamish (Sḵwx̱ x̱ wú7mesh Úxwumixw) andMusqueam(xʷməθkʷə ̓y ̓y əm) nations with a unique focus on neighbours supporting neighbours.

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