Durham Family and Cultural Centre - Student and Family Advocate

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Durham Family and Cultural Centre - Student and Family Advocate - Intake Form

The information gathered will remain confidential. We recognize that that form is personal; however, the information requested is useful and necessary in providing effective support. Please provide information that you feel is relevant, and that you are comfortable sharing.

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Sähköposti *

Mailing Address (Please include Postal Code) *

Student Name *

Student Age *

Student Grade *

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Muu:

Student Gender Identity *

Male

Female

Gender Non -Binary

Transgender

Transgender Girl

Transgender Boy

Two Spirited

Another Gender Identity

Do Not Know

Prefer not to Answer

Muu:

Race

Black (For Example African, African Canadian, Afro Caribbean decent)

East/Southeast Asian (For Example, Chinese, Korean, Japanese, Taiwanese, Filipino, Vietnamese, Cambodian, Thai, Etc

Indigenous (For example, First Nations, Métis or Inuk/Inuit descent)

Latino/Latinx (For example, Latin American, Hispanic descent)

Middle Eastern (For example, Arab, Persian, West Asian descent e.g. Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish, etc.,)

South Asian (For example, South Asian descent, e.g. East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean, etc.)

White (For example, European descent)

Another race category

Prefer not to answer

Tyhjennä valinta

First and still understood language

English

French

Indigenous Language

Another Language(s)

Prefer not to answer

Tyhjennä valinta

What School does child attend *

Family information

Parent/Guardian (1) Name *

Parent/Guardian (1) Contact info (Email and/or Phone) *

Parent/Guardian Gender Identity *

Male

Female

Gender Non -Binary

Transgender

Transgender Woman

Transgender Man

Two Spirited

Another Gender Identity

Do Not Know

Prefer not to Answer

Muu:

Parent/Guardian Race

Black (For Example African, African Canadian, Afro Caribbean decent)

East/Southeast Asian (For Example, Chinese, Korean, Japanese, Taiwanese, Filipino, Vietnamese, Cambodian, Thai, Etc

Indigenous (For example, First Nations, Métis or Inuk/Inuit descent)

Latino/Latinx (For example, Latin American, Hispanic descent)

Middle Eastern (For example, Arab, Persian, West Asian descent e.g. Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish, etc.,)

South Asian (For example, South Asian descent, e.g. East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean, etc.)

White (For example, European descent)

Another race category

Prefer not to answer

Tyhjennä valinta

First and still understood language

English

French

Indigenous Language

Another Language(s)

Prefer not to answer

Tyhjennä valinta

Parent/Guardian (2) Name

Parent/Guardian (2) Contact Information (Email and/or Phone)

Which city does Student reside in? *

Pickering

Ajax

Whitby

Muu:

Areas of Concern (Purpose of Intake) *

Has Student been Identified as having a learning disability? *

Yes

If yes, Please Describe Diagnosis

Does the Student have an IEP? *

Yes

Does Student have any behavioral challenges? *

Yes

Do you have any other support services involved? *

Yes

If yes, Please describe:

Does your child feel engaged in their learning environment? *

Yes

Does your child feel safe, respected and valued in their learning environment? *

Yes

How Confident do you feel navigation the education system?

Low Confidence

High Confidence

Tyhjennä valinta

How did you hear about the Student and Family Advocate? *

Durham Family and Cultural Centre Social Media

From another Durham Family and Cultural Centre Program/Staff Member

Social Media Posts

Durham Black Educators Network (DBEN)

DDSB Website/Newsletter/Staff

Durham Catholic School Board

Community Counsel Meetings

Word of Mouth

Muu:

I Consent to Durham Family and Cultural Centre, Advocating on my behalf at school/school board meetings. I understand I can withdraw these consents verbally at any time. *

I Agree

I Disagree

I consent to the information outlined in this submission being shared with Durham Family and Cultural Centre's internal committees, who can provide advice and information to support me. I understand that I can withdraw this consent verbally at any time. *

I agree

I disagree

I agree that by signing this form Durham Family Cultural Centre can share this information with a trusted third party (e.g. a pro bono legal team) in order to support me in navigating the system. I understand that I can withdraw this consent verbally at any time. *

I agree

I disagree

I understand that Durham Family and Cultural Centre will never share my personal information or story in a public setting without my express consent. I understand that I can withdraw this consent verbally at any time.

I agree

I disagree

Tyhjennä valinta

Lähetä

Tyhjennä lomake

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