BYSSI Form Submission

1
Email* This field is required.Please enter your email address below.
example@example.com
2
Student's Full Name* This field is required.
First Name
Last Name
3
Student's Email Address* This field is required.
example@example.com
4
Student's Gender* This field is required.
Male
Female
Other
5
Date of Birth* This field is required.
Date
Year
Month
Day
6
Self-Identification (check all that apply to your children):* This field is required.
Black
African-Canadian
African
Black-Canadian
Carribean
Other
7
Living Arrangement (check all that apply):* This field is required.
Parent(s)
Grandparent(s)
Caregiver(s)
Other Relative(s)
Other
8
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Mobile/Cell Number
Area Code
Phone Number
10
Home Phone Number
Area Code
Phone Number
11
Parent/Caregiver Information:* This field is required.Please enter the Parent/Caregiver information in the fields specified below (Name, Phone #, Email)
First and Last Name
Phone Number
Email Address
12
Emergency Contact Information* This field is required.
First and Last Name
Phone Number
13
Which School Board do you belong to?* This field is required.Choose District from dropdown.
Peel District School Board
Dufferin-Peel Catholic District School Board
14
What school are you currently attending this Fall?* This field is required.
15
School Services (check all that apply):* This field is required.
Regular Classroom
Bilingual Education (ESL/ELD)
Special Education/IEP
Supervised Alternative Learning (SAL)
Temporary External Learning Link (TELL)
Teen Education and Motherhood (TEAM)
Other
16
Previous Academic Awards?
YesNo
17
If Yes, Please Specify.
18
Do you have any other commitments outside of school? Check as many that apply:
Part-Time Job
Babysitting
Volunteering
Extracurricular Activities (ex. teams, clubs, etc)
Other
19
Are you in need of Volunteer hours?
YesNo
20
Are you interested in a volunteer leadership role within BYSSI? Check as many that apply:
Online Math Tutoring support (grades 9-12)
Online Science Tutoring support (grades 9-12)
Other
21
Are you interested in a volunteer leadership role within your community? Check as many that apply:
Roots Community Services
Free For All Foundation
Malton Neighbourhood Services
22
Are you interested in a leadership role within your school's Black Students’ Association?
Yes
No
Other
23
I/the student would benefit from academic support in the following areas (check all that apply):* This field is required.
Business Studies
Classical Studies and International Languages
Cooperative Education
English as Second Language & English Literacy Development
Health and Physical Education
Mathematics
Social Sciences and Humanities
Art Education
Canadian and World Studies
Computer Studies
English
Guidance and Career Education
Interdisciplinary Studies
Science
Technological Education
Other
24
Student challenges and strengths (list and explain):
Huge
Large
Normal
Small
Ok
Ok
25
Which of the following supports do you believe would benefit the student (check all that apply):* This field is required.
Online Tutoring
Culturally-specific Art and Literacy Lessons
Self-Empowerment Workshops
Health and Wellness Education
Student Advocacy/Mediation
One-on-One online counselling
Leadership and Confidence-building Activities
Black History Education
Life-Skills Training
Online Mentorship
26
Please provide any notes or additional information that you would like to share with BYSSI:
Huge
Large
Normal
Small
Ok
Ok
27
I hereby make a formal application to the BYSSI Collaborative to make support services for physical, mental and emotional well-being, academic success, and meaningful engagement opportunities available to myself, my family and my child. I also understand the BYSSI Collaborative, with my input, will place my child in the most appropriate services to aid in my child’s educational outcome. In consideration of this service and other valuable consideration provided to my family by the BYSSI Collaborative, in its collaborative relationship with Peel District School Board and/or Dufferin-Peel Catholic District School Board, I release the partner agencies and the school board of all responsibilities and liabilities in connection to their services provided in good faith, to myself, my family or my child. I understand that the collection of personal information about myself, my family or my child will be held in strict confidence and will be used solely for the purposes of administering the program. I further agree that information about my child may be shared among members of the BYSSI Collaborative and the Peel District School Board/Dufferin-Peel Catholic District School Board for the purposes of wrap-around service planning. I understand that I am under no obligation for myself, my family or my child to participate in the BYSSI wrap-around program.* This field is required.
Clear
28
Grant permission to the BYSSI Collaborative partners listed below to use the image of myself, my family or my child as marked by my selection(s) below:* This field is required.B.Y.S.S.I Media Consent
Limited usage: I want the image of myself, my family or my child used on printed materials only (no digital or video use).
Unrestricted usage: I agree that these images may be used by the BYSSI Collaborative partners for a variety of promotional purposes (i.e. flyers, social media, etc) and that these images may be used without further notifying me. I do understand that the name of myself, my family or my child will not be used in conjunction with any video or digital image
Deny permission to use myself or my family's image at all.
29
What grade are you in?
Should be Empty: