Beaver Lake Cree Nation COVID-19 Pandemic Census
Please complete the following census form. The data collected will be utilized to support the Nations COVID-19 Pandemic Plan for On and Off-Reserve members.
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1. First and Last Name: *
2. Age: *
3. Mailing Address:
4. Phone:
5. Email:
6. Indian Status Registry Number: *
Note: Your Registry number is 10 digits
7. Location: *
8. If Off-Reserve, please provide location:
9. Are you experiencing homelessness? If you reply yes, please proceed to question 17. *
10. Are you the head of household?
Please note you may be required to submit proof of residency e.g. rental agreement, utility bill, telephone bill.
Clear selection
11.  Number of BLCN registered members in your household, including yourself?
Please provide the number of BLCN registered members in your household. Note: you may be contacted for their Full Name/D.O.B./10 digit Indian Status Registry Number.
12. Elder (60+ yrs old):
13. Adult (18-59 rs old):
14. Youth (13-17 yrs old):
15. Child (4-12 yrs old):
16. Infant/Toddler (3 and under):
17. Do you have internet access? *
18. Did you experience, or do you expect to experience job-loss due to the COVID-19 Pandemic? *
19. If you answered yes, do you, or will you have proof of job-loss from your employer?
Clear selection
20. Are you, or were you on a 14-day self-isolation? *
21. If you answered yes, provide the date you entered self-isolation:
MM
/
DD
/
YYYY
Do you have a disability, limitations and/or special needs? Please identify.
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