{"id":1829,"date":"2020-08-31T15:35:58","date_gmt":"2020-08-31T15:35:58","guid":{"rendered":"https:\/\/cerc-mb.ca\/?page_id=1829"},"modified":"2025-04-22T21:21:24","modified_gmt":"2025-04-22T21:21:24","slug":"intake-form","status":"publish","type":"page","link":"https:\/\/cerc-mb.ca\/en\/intake-form\/","title":{"rendered":"Intake Form"},"content":{"rendered":"<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_4_container\" data-token=\"aba31b823c14b3cdb1112d6226a437e5\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_js_validate \" id=\"form_intakeform\" data-token=\"aba31b823c14b3cdb1112d6226a437e5\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Intake Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"4\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_4\" id=\"frm_hide_fields_4\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"intakeform\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_4\" name=\"frm_submit_entry_4\" value=\"eafa6a9053\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/1829\" \/><div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <div  id=\"field_g7656_label\" class=\"frm_primary_label\">Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_g7656_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_33\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_33-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_g7656_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_g7656_first\" value=\"\" name=\"item_meta[33][first]\" autocomplete=\"given-name\" data-reqmsg=\"Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_33_first_desc\">First<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_33-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_g7656_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_g7656_last\" value=\"\" name=\"item_meta[33][last]\" autocomplete=\"family-name\" data-reqmsg=\"Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_33_last_desc\">Last<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_je8ci\" id=\"field_je8ci_label\" class=\"frm_primary_label\">Phone Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_je8ci\" name=\"item_meta[40]\" value=\"\"  data-reqmsg=\"Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_rvi23\" id=\"field_rvi23_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_rvi23\" name=\"item_meta[41]\" value=\"\"  data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_42_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_3sqn1\" id=\"field_3sqn1_label\" class=\"frm_primary_label\">Mailing Address (Including Postal Code)\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_3sqn1\" name=\"item_meta[42]\" value=\"\"  data-reqmsg=\"Mailing Address (Including Postal Code) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_mxscc\" id=\"field_mxscc_label\" class=\"frm_primary_label\">City \/ Town\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_mxscc\" name=\"item_meta[43]\" value=\"\"  data-reqmsg=\"City \/ Town cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_cxs3r_label\" class=\"frm_primary_label\">Preferred Language (Pick all that apply)\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_cxs3r_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_34-0\">\t\t\t<label  for=\"field_cxs3r-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[34][]\" id=\"field_cxs3r-0\" value=\"English\"  data-invmsg=\"Preferred Language (Pick all that apply) is invalid\"   \/> English<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_34-1\">\t\t\t<label  for=\"field_cxs3r-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[34][]\" id=\"field_cxs3r-1\" value=\"French\"  data-invmsg=\"Preferred Language (Pick all that apply) is invalid\"   \/> French<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_34-2\">\t\t\t<label  for=\"field_cxs3r-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[34][]\" id=\"field_cxs3r-2\" value=\"Other\"  data-invmsg=\"Preferred Language (Pick all that apply) is invalid\"   \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_tsec4_label\" class=\"frm_primary_label\">Language of Service\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_tsec4_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_35-0\">\t\t\t<label  for=\"field_tsec4-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[35][]\" id=\"field_tsec4-0\" value=\"English\"  data-invmsg=\"Language of Service is invalid\"   \/> English<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_35-1\">\t\t\t<label  for=\"field_tsec4-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[35][]\" id=\"field_tsec4-1\" value=\"French\"  data-invmsg=\"Language of Service is invalid\"   \/> French<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_5ca5q_label\" class=\"frm_primary_label\">Referral Source\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_5ca5q_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_37-0\">\t\t\t<label  for=\"field_5ca5q-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[37][]\" id=\"field_5ca5q-0\" value=\"Family \/ Friend\"  data-reqmsg=\"Referral Source cannot be blank.\" data-invmsg=\"Referral Source is invalid\"   aria-required=\"true\"  \/> Family \/ Friend<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_37-1\">\t\t\t<label  for=\"field_5ca5q-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[37][]\" id=\"field_5ca5q-1\" value=\"Provincial Assistance\"  data-reqmsg=\"Referral Source cannot be blank.\" data-invmsg=\"Referral Source is invalid\"   \/> Provincial Assistance<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_37-2\">\t\t\t<label  for=\"field_5ca5q-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[37][]\" id=\"field_5ca5q-2\" value=\"Training Institution\"  data-reqmsg=\"Referral Source cannot be blank.\" data-invmsg=\"Referral Source is invalid\"   \/> Training Institution<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_37-3\">\t\t\t<label  for=\"field_5ca5q-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[37][]\" id=\"field_5ca5q-3\" value=\"Social Media\"  data-reqmsg=\"Referral Source cannot be blank.\" data-invmsg=\"Referral Source is invalid\"   \/> Social Media<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_37-4\">\t\t\t<label  for=\"field_5ca5q-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[37][]\" id=\"field_5ca5q-4\" value=\"Other\"  data-reqmsg=\"Referral Source cannot be blank.\" data-invmsg=\"Referral Source is invalid\"   \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_d2awe_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_d2awe_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_45-0\">\t\t\t<label  for=\"field_d2awe-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[45][]\" id=\"field_d2awe-0\" value=\"Male\"  data-reqmsg=\"Gender cannot be blank.\" data-invmsg=\"Gender is invalid\"   aria-required=\"true\"  \/> Male<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_45-1\">\t\t\t<label  for=\"field_d2awe-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[45][]\" id=\"field_d2awe-1\" value=\"Female\"  data-reqmsg=\"Gender cannot be blank.\" data-invmsg=\"Gender is invalid\"   \/> Female<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_45-2\">\t\t\t<label  for=\"field_d2awe-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[45][]\" id=\"field_d2awe-2\" value=\"Another\"  data-reqmsg=\"Gender cannot be blank.\" data-invmsg=\"Gender is invalid\"   \/> Another<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_45-3\">\t\t\t<label  for=\"field_d2awe-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[45][]\" id=\"field_d2awe-3\" value=\"Not Declared\"  data-reqmsg=\"Gender cannot be blank.\" data-invmsg=\"Gender is invalid\"   \/> Not Declared<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_ebgqk_label\" class=\"frm_primary_label\">Employment Status\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ebgqk_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-0\">\t\t\t<label  for=\"field_ebgqk-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_ebgqk-0\" value=\"Employed\"  data-reqmsg=\"Employment Status cannot be blank.\" data-invmsg=\"Employment Status is invalid\"   aria-required=\"true\"  \/> Employed<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-1\">\t\t\t<label  for=\"field_ebgqk-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_ebgqk-1\" value=\"Not Employed \/ Unemployed\"  data-reqmsg=\"Employment Status cannot be blank.\" data-invmsg=\"Employment Status is invalid\"   \/> Not Employed \/ Unemployed<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-2\">\t\t\t<label  for=\"field_ebgqk-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_ebgqk-2\" value=\"Self Employed\"  data-reqmsg=\"Employment Status cannot be blank.\" data-invmsg=\"Employment Status is invalid\"   \/> Self Employed<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_nbzxs\" id=\"field_nbzxs_label\" class=\"frm_primary_label\">Wage \/ Salary \r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_nbzxs\" name=\"item_meta[47]\" value=\"\"  data-reqmsg=\"Wage \/ Salary  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_7pcx7_label\" class=\"frm_primary_label\">Payment Frequency\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_7pcx7_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-0\">\t\t\t<label  for=\"field_7pcx7-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_7pcx7-0\" value=\"Per Hour\"  data-invmsg=\"Payment Frequency is invalid\"   \/> Per Hour<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-1\">\t\t\t<label  for=\"field_7pcx7-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_7pcx7-1\" value=\"Per Day\"  data-invmsg=\"Payment Frequency is invalid\"   \/> Per Day<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-2\">\t\t\t<label  for=\"field_7pcx7-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_7pcx7-2\" value=\"Per Week\"  data-invmsg=\"Payment Frequency is invalid\"   \/> Per Week<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-3\">\t\t\t<label  for=\"field_7pcx7-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_7pcx7-3\" value=\"Biweekly\"  data-invmsg=\"Payment Frequency is invalid\"   \/> Biweekly<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-4\">\t\t\t<label  for=\"field_7pcx7-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_7pcx7-4\" value=\"Monthly\"  data-invmsg=\"Payment Frequency is invalid\"   \/> Monthly<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-5\">\t\t\t<label  for=\"field_7pcx7-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_7pcx7-5\" value=\"Yearly\"  data-invmsg=\"Payment Frequency is invalid\"   \/> Yearly<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_chb9k\" id=\"field_chb9k_label\" class=\"frm_primary_label\">Highest Education Completed\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_chb9k\" name=\"item_meta[49]\" value=\"\"  data-reqmsg=\"Highest Education Completed cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_wc9xm\" id=\"field_wc9xm_label\" class=\"frm_primary_label\">Year Education Completed\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_wc9xm\" name=\"item_meta[50]\" value=\"\"  data-reqmsg=\"Year Education Completed cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_vmjwb_label\" class=\"frm_primary_label\">Receiving Employment Insurance Benefits\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_vmjwb_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_51-0\">\t\t\t<label  for=\"field_vmjwb-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[51][]\" id=\"field_vmjwb-0\" value=\"Yes\"  data-reqmsg=\"Receiving Employment Insurance Benefits cannot be blank.\" data-invmsg=\"Receiving Employment Insurance Benefits is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_51-1\">\t\t\t<label  for=\"field_vmjwb-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[51][]\" id=\"field_vmjwb-1\" value=\"No\"  data-reqmsg=\"Receiving Employment Insurance Benefits cannot be blank.\" data-invmsg=\"Receiving Employment Insurance Benefits is invalid\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_51-2\">\t\t\t<label  for=\"field_vmjwb-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[51][]\" id=\"field_vmjwb-2\" value=\"Not Declared\"  data-reqmsg=\"Receiving Employment Insurance Benefits cannot be blank.\" data-invmsg=\"Receiving Employment Insurance Benefits is invalid\"   \/> Not Declared<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_ux2sb_label\" class=\"frm_primary_label\">Receiving Income Assistance Benefits\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ux2sb_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-0\">\t\t\t<label  for=\"field_ux2sb-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_ux2sb-0\" value=\"Yes\"  data-reqmsg=\"Receiving Income Assistance Benefits cannot be blank.\" data-invmsg=\"Receiving Income Assistance Benefits is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-1\">\t\t\t<label  for=\"field_ux2sb-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_ux2sb-1\" value=\"No\"  data-reqmsg=\"Receiving Income Assistance Benefits cannot be blank.\" data-invmsg=\"Receiving Income Assistance Benefits is invalid\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-2\">\t\t\t<label  for=\"field_ux2sb-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_ux2sb-2\" value=\"Not Declared\"  data-reqmsg=\"Receiving Income Assistance Benefits cannot be blank.\" data-invmsg=\"Receiving Income Assistance Benefits is invalid\"   \/> Not Declared<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_r9bpm_label\" class=\"frm_primary_label\">Marital Status\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_r9bpm_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_54-0\">\t\t\t<label  for=\"field_r9bpm-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[54][]\" id=\"field_r9bpm-0\" value=\"Married or Equivalent\"  data-reqmsg=\"Marital Status cannot be blank.\" data-invmsg=\"Marital Status is invalid\"   aria-required=\"true\"  \/> Married or Equivalent<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_54-1\">\t\t\t<label  for=\"field_r9bpm-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[54][]\" id=\"field_r9bpm-1\" value=\"Single\"  data-reqmsg=\"Marital Status cannot be blank.\" data-invmsg=\"Marital Status is invalid\"   \/> Single<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_54-2\">\t\t\t<label  for=\"field_r9bpm-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[54][]\" id=\"field_r9bpm-2\" value=\"Not Declared\"  data-reqmsg=\"Marital Status cannot be blank.\" data-invmsg=\"Marital Status is invalid\"   \/> Not Declared<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_hre4o_label\" class=\"frm_primary_label\">Dependants\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_hre4o_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_56-0\">\t\t\t<label  for=\"field_hre4o-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[56][]\" id=\"field_hre4o-0\" value=\"Yes\"  data-reqmsg=\"Dependants cannot be blank.\" data-invmsg=\"Dependants is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_56-1\">\t\t\t<label  for=\"field_hre4o-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[56][]\" id=\"field_hre4o-1\" value=\"No\"  data-reqmsg=\"Dependants cannot be blank.\" data-invmsg=\"Dependants is invalid\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_56-2\">\t\t\t<label  for=\"field_hre4o-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[56][]\" id=\"field_hre4o-2\" value=\"Not Declared\"  data-reqmsg=\"Dependants cannot be blank.\" data-invmsg=\"Dependants is invalid\"   \/> Not Declared<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_57_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_izg9p\" id=\"field_izg9p_label\" class=\"frm_primary_label\">Dependants (If applicable)\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_izg9p\" name=\"item_meta[57]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_u0yv0_label\" class=\"frm_primary_label\">Disability\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_u0yv0_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_58-0\">\t\t\t<label  for=\"field_u0yv0-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[58][]\" id=\"field_u0yv0-0\" value=\"Yes\"  data-reqmsg=\"Disability cannot be blank.\" data-invmsg=\"Disability is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_58-1\">\t\t\t<label  for=\"field_u0yv0-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[58][]\" id=\"field_u0yv0-1\" value=\"No\"  data-reqmsg=\"Disability cannot be blank.\" data-invmsg=\"Disability is invalid\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_58-2\">\t\t\t<label  for=\"field_u0yv0-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[58][]\" id=\"field_u0yv0-2\" value=\"Not Declared\"  data-reqmsg=\"Disability cannot be blank.\" data-invmsg=\"Disability is invalid\"   \/> Not Declared<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_3w4in_label\" class=\"frm_primary_label\">Visible Minority\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_3w4in_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_59-0\">\t\t\t<label  for=\"field_3w4in-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[59][]\" id=\"field_3w4in-0\" value=\"Yes\"  data-reqmsg=\"Visible Minority cannot be blank.\" data-invmsg=\"Visible Minority is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_59-1\">\t\t\t<label  for=\"field_3w4in-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[59][]\" id=\"field_3w4in-1\" value=\"No\"  data-reqmsg=\"Visible Minority cannot be blank.\" data-invmsg=\"Visible Minority is invalid\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_59-2\">\t\t\t<label  for=\"field_3w4in-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[59][]\" id=\"field_3w4in-2\" value=\"Not Declared\"  data-reqmsg=\"Visible Minority cannot be blank.\" data-invmsg=\"Visible Minority is invalid\"   \/> Not Declared<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_961zj_label\" class=\"frm_primary_label\">Indigenous Status\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_961zj_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-0\">\t\t\t<label  for=\"field_961zj-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_961zj-0\" value=\"Inuit\"  data-reqmsg=\"Indigenous Status cannot be blank.\" data-invmsg=\"Indigenous Status is invalid\"   aria-required=\"true\"  \/> Inuit<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-1\">\t\t\t<label  for=\"field_961zj-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_961zj-1\" value=\"Metis\"  data-reqmsg=\"Indigenous Status cannot be blank.\" data-invmsg=\"Indigenous Status is invalid\"   \/> Metis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-2\">\t\t\t<label  for=\"field_961zj-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_961zj-2\" value=\"Status-on Reserve\"  data-reqmsg=\"Indigenous Status cannot be blank.\" data-invmsg=\"Indigenous Status is invalid\"   \/> Status-on Reserve<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-3\">\t\t\t<label  for=\"field_961zj-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_961zj-3\" value=\"Status-off Reserve\"  data-reqmsg=\"Indigenous Status cannot be blank.\" data-invmsg=\"Indigenous Status is invalid\"   \/> Status-off Reserve<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-4\">\t\t\t<label  for=\"field_961zj-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_961zj-4\" value=\"Non-status\"  data-reqmsg=\"Indigenous Status cannot be blank.\" data-invmsg=\"Indigenous Status is invalid\"   \/> Non-status<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-5\">\t\t\t<label  for=\"field_961zj-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_961zj-5\" value=\"No\"  data-reqmsg=\"Indigenous Status cannot be blank.\" data-invmsg=\"Indigenous Status is invalid\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-6\">\t\t\t<label  for=\"field_961zj-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_961zj-6\" value=\"Not Declared\"  data-reqmsg=\"Indigenous Status cannot be blank.\" data-invmsg=\"Indigenous Status is invalid\"   \/> Not Declared<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_px6xm_label\" class=\"frm_primary_label\">Immigrant \/ Refugee\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_px6xm_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_61-0\">\t\t\t<label  for=\"field_px6xm-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[61][]\" id=\"field_px6xm-0\" value=\"Yes\"  data-reqmsg=\"Immigrant \/ Refugee cannot be blank.\" data-invmsg=\"Immigrant \/ Refugee is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_61-1\">\t\t\t<label  for=\"field_px6xm-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[61][]\" id=\"field_px6xm-1\" value=\"No\"  data-reqmsg=\"Immigrant \/ Refugee cannot be blank.\" data-invmsg=\"Immigrant \/ Refugee is invalid\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_61-2\">\t\t\t<label  for=\"field_px6xm-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[61][]\" id=\"field_px6xm-2\" value=\"Not Declared\"  data-reqmsg=\"Immigrant \/ Refugee cannot be blank.\" data-invmsg=\"Immigrant \/ Refugee is invalid\"   \/> Not Declared<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_yosys\" id=\"field_yosys_label\" class=\"frm_primary_label\">Landing Date (If Applicable)\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_yosys\" name=\"item_meta[62]\" value=\"\"  data-reqmsg=\"Landing Date (If Applicable) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first vertical_radio\">\r\n    <div  id=\"field_lccrt_label\" class=\"frm_primary_label\">Consent\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_lccrt_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_69-0\">\t\t\t<label  for=\"field_lccrt-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[69][]\" id=\"field_lccrt-0\" value=\"I have read and signed Privacy &amp; Consent Form above\"  data-reqmsg=\"Consent cannot be blank.\" data-invmsg=\"Consent is invalid\"   aria-required=\"true\"  \/> I have read and signed Privacy &amp; Consent Form above<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n    <label for=\"field_8yd3c\" id=\"field_8yd3c_label\" class=\"frm_primary_label\">What are the services that you are hoping to get help with? (eg. Resume, Cover letter, Educational Funding, Job Search Services, etc. )\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[71]\" id=\"field_8yd3c\" rows=\"5\"  data-invmsg=\"What are the services that you are hoping to get help with? (eg. Resume, Cover letter, Educational Funding, Job Search Services, etc. ) is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_105_container\" class=\"frm_form_field form-field \">\r\n\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_131_container\">\n\t\t\t<label for=\"field_bgm5e\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_bgm5e\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[131]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"rlOczEdd2HfO8biiMuv3QK\/DRvjkct3FBUZ6V9Hcu0o=\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n<p>&nbsp;<\/p>\n<p><strong>Consent Form<\/strong><\/p>\n\n\t\t<style type=\"text\/css\">\n\t\t\t#gallery-1 {\n\t\t\t\tmargin: auto;\n\t\t\t}\n\t\t\t#gallery-1 .gallery-item {\n\t\t\t\tfloat: left;\n\t\t\t\tmargin-top: 10px;\n\t\t\t\ttext-align: center;\n\t\t\t\twidth: 33%;\n\t\t\t}\n\t\t\t#gallery-1 img {\n\t\t\t\tborder: 2px solid #cfcfcf;\n\t\t\t}\n\t\t\t#gallery-1 .gallery-caption {\n\t\t\t\tmargin-left: 0;\n\t\t\t}\n\t\t\t\/* see gallery_shortcode() in wp-includes\/media.php *\/\n\t\t<\/style>\n\t\t<div id='gallery-1' class='gallery galleryid-1829 gallery-columns-3 gallery-size-large'><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/cerc-mb.ca\/en\/intake-form\/privacy-notice-and-consent-form-2025_page-0001\/'><img decoding=\"async\" width=\"680\" height=\"880\" src=\"https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0001-791x1024.jpg\" class=\"attachment-large size-large\" alt=\"\" srcset=\"https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0001-791x1024.jpg 791w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0001-232x300.jpg 232w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0001-768x994.jpg 768w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0001-1187x1536.jpg 1187w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0001-958x1240.jpg 958w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0001.jpg 1275w\" sizes=\"(max-width: 680px) 100vw, 680px\" \/><\/a>\n\t\t\t<\/dt><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/cerc-mb.ca\/en\/intake-form\/privacy-notice-and-consent-form-2025_page-0002\/'><img decoding=\"async\" width=\"680\" height=\"880\" src=\"https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0002-791x1024.jpg\" class=\"attachment-large size-large\" alt=\"\" srcset=\"https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0002-791x1024.jpg 791w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0002-232x300.jpg 232w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0002-768x994.jpg 768w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0002-1187x1536.jpg 1187w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0002-958x1240.jpg 958w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0002.jpg 1275w\" sizes=\"(max-width: 680px) 100vw, 680px\" \/><\/a>\n\t\t\t<\/dt><\/dl><dl class='gallery-item'>\n\t\t\t<dt class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/cerc-mb.ca\/en\/intake-form\/privacy-notice-and-consent-form-2025_page-0003\/'><img decoding=\"async\" width=\"680\" height=\"880\" src=\"https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0003-791x1024.jpg\" class=\"attachment-large size-large\" alt=\"\" srcset=\"https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0003-791x1024.jpg 791w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0003-232x300.jpg 232w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0003-768x994.jpg 768w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0003-1187x1536.jpg 1187w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0003-958x1240.jpg 958w, https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0003.jpg 1275w\" sizes=\"(max-width: 680px) 100vw, 680px\" \/><\/a>\n\t\t\t<\/dt><\/dl><br style=\"clear: both\" \/>\n\t\t<\/div>\n\n<p><a class=\"fasc-button fasc-size-medium fasc-type-flat\" style=\"background-color: #6ccbf0; color: #ffffff;\" target=\"_blank\" href=\"https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Fillable-Intake-form_Consent_2025_Workshops.pdf\">Intake Form PDF version<\/a><\/p>\n<p><a class=\"fasc-button fasc-size-medium fasc-type-flat\" style=\"background-color: #70c8eb; color: #ffffff;\" href=\"https:\/\/cerc-mb.ca\/contact-us\/\">Contact us<\/a><\/p>\n<p>&nbsp; &nbsp; &nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; Consent Form Intake Form PDF version Contact us &nbsp; &nbsp; &nbsp;<\/p>\n","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1829","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Intake Form - CERC<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/cerc-mb.ca\/en\/intake-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Intake Form - CERC\" \/>\n<meta property=\"og:description\" content=\"&nbsp; Consent Form Intake Form PDF version Contact us &nbsp; &nbsp; &nbsp;\" \/>\n<meta property=\"og:url\" content=\"https:\/\/cerc-mb.ca\/en\/intake-form\/\" \/>\n<meta property=\"og:site_name\" content=\"CERC\" \/>\n<meta property=\"article:modified_time\" content=\"2025-04-22T21:21:24+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/cerc-mb.ca\/wp-content\/uploads\/2025\/04\/Privacy-Notice-and-Consent-Form-2025_page-0001-791x1024.jpg\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/cerc-mb.ca\\\/en\\\/intake-form\\\/\",\"url\":\"https:\\\/\\\/cerc-mb.ca\\\/en\\\/intake-form\\\/\",\"name\":\"Intake Form - 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