Client Registration Form First Name & Middle InitialFamily NameGender Male Female Marital Status: Married or Equivalent Single Single Parent Number of DependentsAge of DependentsDate of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeEmployment Status: Employed Unemployed Student Language preference: English French Other (Specify): Metis Inuit Non-Status Non-Aboriginal Status Metis Membership NumberMMF LocalMMF RegionAddress Street Address City ZIP / Postal Code Email Address Home/Cell NumberHave you previously been sponsored by the MMF for activities? Yes No If yes, which activities?Start date:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End date:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have any health problems we should be aware of? Yes No If yes, please specify:Do you consider yourself to be a person with a disability? Yes No If yes, please specify:Do you need any special equipment? Yes No If yes, please specify:Highest Level of Education Attained:Primary / Secondary (Grade):Year Attained:Diploma or GED Received? Yes No If you have attended Post-Secondary studies did you obtain a: Certificate Diploma Degree Bachelors Degree Masters Degree Name of Course attended:Program Length:If you are currently attending Post-Secondary studies please provide:Name of institution:Expected completion date:Permission to use Photograph/Video Subject: UPIP Funded Activities I grant to Manitoba Metis Federation, its representatives and employees the right to take photographs/videos of me and my property in connection with the above-identified subject. I authorize Manitoba Metis Federation, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Manitoba Metis Federation may use such photographs/videos of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.I have read and understand the above:Signature:Date:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Printed Name:Signature, parent or guardian (if under age 18):Date:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920FOR STAFF USE ONLY: What services are being provided or what project is UPIP client participating in.