Better at Home *denotes required fields per UWLM reporting requirements Participant Information Contact Details First Name* Middle Name Last Name* Your email* Phone Phone (secondary) Applicant Info Date of Birth* Age* Living Arrangement*Living AloneDo Not Live AloneUnknown Gender*—Please choose an option—MaleFemalePrefer Not to DiscloseUnknownOther Ethnic Origin*—Please choose an option—Prefer Not to DiscloseUnknownAnglo-CanadianFrench-Canadian (Quebecois, Acadian)EuropeanAfricanNorth American Indigenous (First Nations, Indigenous, Metis, Inuit)OceaniaEast/South East Asian (Chinese, Vietnamese, Japanese)South Asian (Indian, Pakistani)West Asian/Middle Eastern (Persian)CaribbeanLatin or Central or South AmericanOtherPrefer not to disclose Preferred Language*—Please choose an option—EnglishFrenchIndigenous LanguageGermanKoreanMandarinCantonesePunjabiTagalogFarsiSpanishOther Personal Health Number (PHN) Participant Address Street Address* Address Line 2 City* Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan Postal Code* Access Instructions (Buzzer# etc.) Emergency Contact First Name Last Name Email Relationship Phone(primary) Phone(secondary) Lifeline / Lockbox / PIN This form uses Akismet to reduce spam. Learn how your data is processed.Δ