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.
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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?
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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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