Statistical Information Please be advised that filling in this form

Statistical Information
Please be advised that filling in this form MANDATORY
CCS Community Services, who runs Camp Kinkora, receives funding from Centraide of Greater Montreal. This funding allows us to offer
camp at affordable prices. In order to ensure that we continue with these affordable fees, we need you to full in this form. Please be
assured that no names are required, this is strictly confidential. Thank you for your time and understanding.
1. Please indicate which family income bracket you fall in to based on the number of individuals in your
household./ SVP, indiquez le nombre de personnes dans la famille et votre revenu familial:
Family
Size and
Income
1 person
$0$22,999
$23,000$27,999
$28,000$33,999
$34,000$40,999
$41,000$46,999
$47,000$52,999
$53,000$58,999
$59,000$89,999
$90,000
and over
2 people
3 people
4 people
5 people
6 people
7+ people
2. The ethno cultural origins listed below are those provided by Centraide of Greater Montreal and cannot be
modified by CCS. Please indicate which best applies to you. / Les catégories d’origines ethnoculturelles ici
listées sont celles fournies par CENTRAIDE et ne peuvent être modifiées par le CCS. Nous vous prions d’indiquer
laquelle de ces catégories vous convient le mieux
Select ONE only – Veuillez choisir UN SEUL catégorie :
a.
b.
c.
d.
e.
f.
g.
French
British
Italian
Haitian
Arab
Chinese
Greek
h.
i.
j.
k.
l.
m.
n.
South Asian
Portuguese
African
Latin, Central, or South American
West Indian
Native American
Other. Please specify ______________
3. Please indicate which borough the camper lives in (i.e. Pierrefonds, Pointe-St-Charles, Saint-Henri, etc.). /SVP
indiquez dans quel quartier le campeur demeure: ___________________________________________________
4. Language most often spoken at home / Langue Maternelle (Langue parlée le plus souvent à la maison):
a. English
b. French
c. Spanish
d. Other. Please specify ______________
5. Second most often spoken language at home / Deuxième langue parlée le plus souvent à la maison :
a. English
b. French
c. Spanish
d. Other. Please specify ______________
6. Gender of Camper: a) Male ______
7.
b) Female ________
Age of Camper: ____________________
8. Please indicate which camp program you attended / S.V.P. écrivez le nom du camp auquel vous-avez
participé? _______________________________________ (ex. Camp Positif, Visions, Trail’s End)
Number of nights stayed at camp / Nombre de nuités au camp : _______________
Thank you for your time. Have a wonderful time at camp!
Merci Beaucoup!