Intake Form

Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

Password must contain the following:

12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

Welcome to Easter Seals Alberta

Easter Seals Alberta is committed to providing resources, information, and support to families raising children, youth, and adults with disabilities.

Our team is dedicated to fostering a safe, respectful, and non-judgmental environment where you can access the support and resources you need. Our experienced Resource Coordinators are here to guide you every step of the way.

Please note that Easter Seals Alberta does not have a crisis response team or professional counsellors on staff. If you are in crisis, we encourage you to contact the 24-hour Mental Health Help Line (toll-free within Alberta) at 1-877-303-2642. Your well-being is important to us.

If you need support with filling out this intake or would like to speak to our team, please send us an email: support@easterseals.ab.ca, or give us at call: (403) 235-5662.

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

*Required

Parent #1 Information

Parent #1 / Legal Guardian First Name:

Parent #1 / Legal Guardian Last Name:

Parent #1 / Legal Guardian Email Address:

Parent #1 / Legal Guardian Phone Number:

Gender Identity

Pronouns

Parent #2 Information(If Applicable)

Parent #2 / Legal Guardian First Name :

Parent #2 / Legal Guardian Last Name :

Parent #2 / Legal Guardian Email Address :

Parent #2 / Legal Guardian Phone Number ;

Gender Identity

Pronouns

Language(s) spoken:

Other Languages

Do you need language support (translator)?

YesNo

Indigenous Identity

Status in Canada:

Other: Status:

Address

Street Address

Apt/Unit #

City

State/Province

Postal Code

Child/ Dependent Information

Child / Dependent's First Name:

Child / Dependent's Last Name:

Child / Dependent's Date of Birth:

Gender Identity

Pronouns

Child / Dependent's Diagnosis / Medical Condition(s):

Specific Diagnosis

Other : Disabilities

Please select the program you’d like to apply for

Please describe your reason for support:

How did you hear about Easter Seals Alberta?

Would you like to receive information and future communication from Easter Seals Alberta?

YesNo

Save my progress and resume later | Resume a previously saved form

Contact Information