Membership Application

The following can be completed by the individual, family and / or referring agent:

Just fill in required information in white boxes, and checks provided. When completed, just hit SUBMIT at bottom of page.
  Personal Information
   
 
Applicant's name
Last name
First name
   
 
Date of Birth
mm/dd/yy
Sex
Male:
Female:
   
Address
Street/City/Province/Postal Code
Apt.#

 
Phone Number
Home#
Health Card Number

 
Primary Language
(spoken, written)
Marital Status
 
   
 
Do you wear a Medical-Alert Bracelet or Necklace?
Yes
No
   
 
Do you require services in Language other than English?
If so, please state:
   
 

Brain Injury Information
Date of injury: Cause of injury((e.g. anoxia, assault, motor vehicle accident, fall, etc.)
   
  Personal Support Network/Emergency Contacts
   
 
Contact name #1
Last name
First name
Relationship
   
 
Contact Person
Yes
No
   
 
Address
Street/City/Province/Postal Code
Apt.#
   
 
Phone Number
Home#
Work #
   
 
Contact name #2
Last name
 First name
Relationship
   
 
Contact Person
Yes
No
   
 
Address
Street/City/Province/Postal Code
Apt.#
   
 
Phone Number
Home#
Work #
   
  Education
   
 
School
Name and Address of last school attended
Level attained:
Year completed
   
  Employment
   
 
Name of last Employer:
Name:
Position:
Length of Employment
   
  Reason for Referral
   
 
Individual
(What would you like to achieve through participating in the Clubhouse?):
   
 
Living situation
Please describe current living situation (e.g. share apartment with brother)
   
 
Primary Support
Whom do you rely on for your primary support and assistance? Please list their names and relationship to you.
   
 
Other services requested
Have services from any other agencies been requested? (e.g. Vocation Rehabilitation, Residential support)
Yes
No
If yes, please specify using name of agency, date and status of application:
   
 
Recieving other services
Are you currently receiving any services?
Yes
No
If yes, please include the agency, your contacts name, address and phone number:
   
 

As a part of the admission process and as a means of preserving the integrity of Cornerstone Clubhouse, a copy of a clinical record (i.e. neuropsychological report) is required, confirming your acquired brain injury.
 

Submit Application: