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Building Futures - Intake Form
Register for our essential skills training! We will be contacting you for an in-person meeting to discuss expectations and determine eligibility.
Name (first, last)
Your answer
Date of Birth
MM
/
DD
/
YYYY
Email
Your answer
Phone #
Your answer
Emergency Contact - Full Name
Your answer
Emergency Contact Phone #
Your answer
Highest level of education completed (ie - certificate, diploma, last completed grade level)
Your answer
Interests
Your answer
Which part of the program interests you the most?
Job Week (not currently offered)
Essential life skills
Pre-employment
Healthy living
Moving forward
Clear selection
Do you have any health concerns we should know about or dietary restrictions?
Your answer
Are you comfortable with doing group activities?
Yes
No
Clear selection
Are there any current behaviors that we should be aware of that might pose a safety concern to you or others attending the program?
Your answer
If you are under 18 years of age, we will require permission from your parent or guardian to attend. Will we be able to contact your parent/guardian for this permission?
Yes
No
If you answered yes above, please provide parent/guardian name and contact number.
Your answer
If you currently require a support person for activities, it is mandatory that an adult accompany you to this program. Will a support person be with you?
Yes
No
Clear selection
What would you like to achieve through this program?
Your answer
I confirm that all the information above is accurate
(by filling in your name, you are signing this form).
Your answer
Thanks so much for your submission. We will be in touch soon to arrange an intake meeting so we can get started!
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This form was created inside of North Peace Youth Support Association.
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