Name: First Last Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone:Email: Son/daughter's name: First Last Son/Daughter's Date of Birth: Date Format: MM slash DD slash YYYY Gender: Male Female Diagnosis:What region of the province are you from?Abrams VillageAlbertonBorden-CarltonCharlottetownCornwallCrapaudElmiraGeorgetownHunter RiverInvernessKensingtonMiscoucheMontagueMorellMount CarmelMount StewartMurray HarbourO'LearySourisStratfordSummersideTignishTyne ValleyVernon RiverWood IslandsOther:What days are you looking for the 1:1 worker to work for you? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Day time from: : HH MM AM PM Day time to: : HH MM AM PM Night time from: : HH MM AM PM Night time to: : HH MM AM PM Overnight Respite beginning on what day and time and ending on what day and time. Please specify.PEI ACL is committed to respecting the personal privacy of individuals and families and does not trade, rent or sell your personal information to any 3rd party. When the PEI ACL Family Inclusion Facilitator identifies a potential match for you, you will receive an email from familysupport@peiacl.org. The e-mail will contain a list of individuals who identified to ACL that they are available for work. It is your responsibility to contact and interview the potential 1:1 workers to ensure they are right individuals for your family member and that all Police Records and Vulnerability Checks are valid. Disclaimer: This information is provided as a public service to Island Families who have a loved one with a Disability looking for 1:1 workers to work with their loved one. Information on this site is protected by copyright and all rights are reserved. By visiting this site, you accept all the terms and conditions outlined below. If you do not accept these terms and conditions please leave this site. This Web site and all of the information it contains are provided "as is" without warranty of any kind, whether express or implied. PEI ACL cannot warrant or guarantee the accuracy, completeness or fitness of this information for any particular purpose. All implied warranties, including, without limitation, implied warranties of merchantability, fitness for a particular purpose, and non-infringement, are hereby expressly disclaimed. In addition, the content of this site is subject to change. While PEI ACL is committed to updating the information on our website, we cannot guarantee that it is up to date when you access it. Limitation of Liabilities: Under no circumstances will PEIACL be liable to any person or business entity for any direct, indirect, special, incidental, consequential, or other damages based on any use of this Web site or any other Web site to which this site is linked, including, without limitation, any lost profits, business interruption, or loss of programs or information, even if PEI ACL has been specifically advised of the possibility of such damages.CAPTCHA
