Government of Yukon

Health and Social Services

A to Z forms

 Adoption

 Accessing Adoption Records from Yukon Government and Family and Children's Services
         English French PDF (yg5654)

 Cancel a Disclosure Veto or No-Contact Declaration
         English French PDF (yg5652)

 Statutory Declaration and Undertaking
         English French PDF (yg5651)

 Disclosure Veto and Statement
         English French PDF (yg5655)

 No-Contact Declaration and Statement
         English French PDF (yg5653)

 Identification Particulars of Adopted Person
         English French PDF (yg5696)


 Adult Protection and Decision-Making Act

 Representation Agreement Form
         English French PDF (yg5256)

 Supported Decision-Making Agreement Form
         English French PDF (yg5255)


 Birth Certificates

 Birth Certificate Application
         Bilingual PDF (YG3385)


 Care Consent Act Forms

 Abbreviated Advance Directive
         Bilingual PDF (yg5394)

 Emergency Medical Information Form
         Bilingual PDF (yg5571)

 Form 1 (CCA) - Certificate of Legal Consultation
         English French PDF (yg5260)

 Form 2 (CCA) - Certificate of Need for Financial Protection
         English French PDF (yg5257)

 Form 3 (CCA) - Cancellation of Certificate of Need for Financial Protection
         English French PDF (yg5258)

 Form 4 (CCA) - Statement by a Close Friend before they are Chosen as a Substitute Decision-Maker
         English PDF (yg5283)

 Form 5 (CCA) - Last Resort Substitute Consent by Care Providers
         English PDF (yg5282)

 Form 6 (CCA) - Application to the Capability and Consent Board for matters under the Care Consent Act
         English PDF (yg5284)

 Resuscitation and Care form
         English PDF (yg5262)


 Change of Name

 Application for Name Change of an Adult
         Bilingual PDF (YG3401)

 Application for Change of Name: Dependant Children
         Bilingual PDF (YG3404)


 Child Care

 Application for Childcare Enhancement Funding
         English French PDF (YG4864)

 Application for Child Care Subsidy Form
         English French PDF (YG4586)

 Attendance Record – Direct Operating Grant
         English French PDF (YG5702)

 Child Care Subsidy – Affidavit – Separated
         English French PDF (YG5351)

 Child Care Subsidy – Affidavit – Single
         English French PDF (YG6448)

 Child Care Subsidy - Eligibility Form
         English French PDF (YG2279)

 Child Care Subsidy - Job Search Record
         English French PDF (YG3871)

 Child Care Subsidy – Self-Employed Financial Information
         English French PDF (YG3958)

 Child Care Subsidy – Special Needs Application
         English French PDF (YG3957)

 Child Care Subsidy - Verification of Income by Employer
         English French PDF (YG3956)

 Family Day Home Menu Declaration
         English French PDF (YG5703)


 Child and Family Services Act

 Accessing Adoption Records from Yukon Government, Family and Children's Services
         English French PDF (yg5654)

 Cancel a Disclosure Veto or No-Contact Declaration
         English French PDF (yg5652)

 Disclosure Veto and Statement
         English French PDF (yg5655)

 Identification Particulars of Adopted Person
         English French PDF (yg5696)

 No-Contact Declaration and Statement
         English French PDF (yg5653)

 Statutory Declaration and Undertaking
         English French PDF (yg5651)


 Continuing Care

 Incident Report
         English PDF (YG5783)

 Infection Control Report
         English PDF (YG5784)

 Medication Incident Report
         English PDF (YG5785)

 Volunteer Services (Volunteer Satisfaction Survey)
         English French PDF (yg5523)

 Volunteer Services (Volunteer Exit Survey)
         English French PDF (yg5530)


 Death Certificates

 Death Certificate Application
         Bilingual PDF (YG3385)


 Environmental Health Services

 Sewage Disposal System - Notification of Abandonment and Reclamation
         English French PDF (YG5589)

 Septic Tank and Sewage Holding Tank Installation Declaration
         English French PDF (YG5742)

 Sewage Holding Tank - Notification of Installation and Undertaking to Maintain
         English French PDF (YG4673)

 Septic Tank and Soil Absorption System - Notification of Installation and Undertaking to Maintain
         English French PDF (YG4674)

 Sewage Holding Tanks - Electrical Assurance
         English French PDF (YG6325)

 Sewage Pump-Up Systems - Electrical Assurance
         English French PDF (YG6326)

 Consent to Release Information
         English French PDF (YG4684)

 Sewage Disposal System - Application for Approval to Use
         English French PDF (YG5964)

 Food Vending Vehicle - Application-Checklist for a Permit to Operate
         English French PDF (YG5922)

 Sewage Disposal System - Application for a Permit to Install
         English French PDF (YG4307)

 Sewage Disposal System - Application for Permission to Retain
         English French PDF (YG5073)

 Drinking Water - Application for a Permit to Operate a Large Public Drinking Water System
         English PDF (YG5453)

 Drinking Water - Application for a Permit to Operate a Trucked Drinking Water Distribution System
         English PDF (YG5452)

 Drinking Water - Bacteriological Analysis of Drinking Water Batch Submission Form
         Bilingual PDF (YG5776)

 Privy - Application for Authorization to Construct, Install and/or use a Privy
         Bilingual PDF (YG5438)

 Sewage Disposal System - Evidence Requirements for Approval to Use
         English French PDF (YG5965)

 Sampling Site Information Form
         Bilingual PDF (YG5777)

 Environmental Health Services Survey
         English French PDF (YG5984)

 Sewage Disposal System - Photographic Record Submission Requirements of the Stages of Installation
         English French PDF ()


 Immunization

 Consent for School Immunizations - Grade 6
         English French PDF (YG5788)

 Consent for School Immunizations - Grade 9
         English French PDF (yg5838)


 Insured Health

 Temporary Absence
         English French PDF (YG3383)

 YHCIP Notice of Change
         Bilingual PDF (YG679)


 Marriage Certificates

 Marriage Certificate Application
         Bilingual PDF (YG3385)


 Marriage Commissioner

 Marriage Commissioner Application Form
         English French PDF (YG6102)


 Medical Travel

 Out-of-Territory Medical Travel Subsidy Form
         English French PDF (YG4840)

 Out-of-Territory Medical Travel via Road to Scheduled Appointments
         English French PDF (YG4857)


 Mental Health Act

 Form 1 - Application for Order for Involuntary Examination
         English PDF (yg3983)

 Form 2 - Order to Apprehend
         English PDF (yg3984)

 Form 3 - Statement of Peace Officer on Apprehension
         English PDF (yg3985)

 Form 4 - Reccomendation for Involuntary Psychiatric Assessment (Physician)
         English French PDF (yg3986)

 Form 5 - Recommendation for Involuntary Psychiatric Assessment (Nurse)
         English French PDF (yg3987)

 Form 6 - Patient's Right to be Informed
         English PDF (yg4077)

 Form 7 - Certificate of Involuntary Admission
         English French PDF (yg3989)

 Form 8 - Waiver of Right to an Automatic Hearing
         English PDF (yg5281)

 Form 9 - Application to the Capability and Consent Board for Matters under the Mental Health Act
         English PDF (yg3988)

 Form 10 - Authorization for Specified Treatment
         English PDF (yg3996)

 Form 11 - Certificate of Renewal of Involuntary Admission
         English PDF (yg3997)

 Form 12 - Certificate of Change of Status
         English PDF (yg3998)

 Form 13 - Notice of Intention to Transfer an Involuntary Patient (Yukon Resident)
         English PDF (yg3990)

 Form 14 - Renewal of Proposed Patient Transfer
         English PDF (yg4000)

 Form 15 - Application for Transfer of a Non-Resident Involuntary Patient
         English PDF (yg4002)

 Form 16 - Temporary Release of Involuntary Patient
         English PDF (yg4003)

 Form 17 - Certificate of Return
         English PDF (yg4004)

 Form 18 - Application to Withhold Clinical Record
         English PDF (yg4005)

 Form 19 - Request for Correction of the Clinical Record
         English PDF (yg4006)

 Form 20 - Statement of Disagreement with a Clinical Record
         English PDF (yg4007)

 Form 21 - Consent of Disclosure, Transmittal or Examination of a Patient Record
         English PDF (yg4008)


 Pioneer Utility Grant

 Pioneer Utility Grant Application 2015
         English French PDF (YG1666)

 Pioneer Utility Grant Certificate of Tenancy 2015
         English French PDF (YG6234)


 Public Health and Safety Act (For Doctors Only)

 Congenital Anomalies Surveillance Yukon (CASY) Referral Form
         English French PDF (YG5848)

 Congenital Anomalies Surveillance Yukon (CASY) - Child
         English French PDF (5914)

 Congenital Anomalies Surveillance Yukon (CASY) - Mother/Fetus
         English French PDF (5849)


 Rabies Protocol

 Rabies Risk Investigation Form ‘A’
         English PDF (YG5812)

 Rabies Risk Investigation Form ‘B’
         English PDF (YG5813)


 Record of User Activity

 Record of User Activity Request Form
         English French PDF (YG6379)

 Request for Access to Personal Information Records
         English French PDF (YG6364)


 Temporary Absence

 Temporary Absence
         English French PDF (YG3383)


 Travel for Medical Treatment


 Yukon Children’s Dental Program

 Consent for Examinations and Prevention Services
         Bilingual PDF (YG4819)