Around Art & Land | Elevating my Dreams

Intake Form Around Art & Land

Elevating my Dreams
SECTION 1: PROGRAM INFORMATION

Elevating my Dreams

Participants will be invited to create kites using multiple recycled materials with messages they would like to share with all flying creatures.

Dates: Saturdays, July 9th, 16th, 23rd

Time: 11 am to 12:30 pm

For any questions or if you need assistance to fill out this application please email Julián Carvajal, julian@northyorkarts.org
SECTION 2: CONTACT INFORMATION
Name *

First Name Last Name
Preferred Name
Date of birth *

Day Month Year
Date
Postal Code *
Area you live in: *

North York East York or the beaches Scarborough Etobicoke York Downtown or Midtown Toronto GTA Other
Personal Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Phone Number *
Please enter a valid phone number.
Parent/Guardian Email *
example@example.com
Emergency Contact
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number *
Please enter a valid phone number.
Section 3: PROGRAM QUESTIONS
Why are you interested in this program? *
Tell us a bit about your neighbourhood: *
I am available to attend the following program dates: *

Saturday, July 9, from 11:00 am to 12:30 pm Saturday, July 16, from 11:00 am to 12:30 pm Saturday, July 23, from 11:00 am to 12:30 pm
Please tell us if you have any specific needs in order to participate in this program: *
SECTION 4: OUTREACH
How did you hear about the program? *

NYA’s social media Other social media NYA’s newsletter NYA’s Website Printed Flyer Word of mouth (friend, family, teacher, etc.) Other
Did you know about North York Arts before this program? *

Yes No
Would you like to subscribe to our monthly e-newsletter? *

Yes No
SECTION 5: DATA COLLECTION -Optional
Why are we collecting this data? North York Arts is strongly committed to equity and inclusion in our programs. With this in mind, we have set out specific programming goals in our strategic plan to better serve our communities. To ensure that we do so, we are collecting data on how our participants self-identify. This is completely optional but we appreciate your input.
Pronouns:

She/Her He/Him They/ Them Prefer not to disclose Other
Gender Identity:

Two-Spirit Non-binary Trans Female Male Prefer not to disclose Other
Ethnicity & Race: (If you’re comfortable, we encourage you to be specific about how you identify, this helps North York Arts better serve our communities.)

Indigenous to Turtle Island Black Person of colour (non-Caucasian in race or non-white in colour) Prefer not to disclose Other
Are you a Newcomer, Refugee, or Immigrant to Canada?

Newcomer (immigrated to Canada less than 7 years ago) Refugee claimant or status Immigrant (immigrated to Canada over 7 years ago) None of the above Prefer not to disclose Other
What is your first language?
Do you identify as a person part of the 2SLGBTQ+ community?

Yes No Prefer not to disclose
Do you identify as part of the Deaf and Disabled community?

Yes No Prefer not to disclose
SECTION 6: SUBMISSION
Photo/Video Release

As a participant of North York Arts programming and events, we use your photographs and video for documentation and promotional purposes. We are seeking your permission for a photo or video of you to be taken and used for publication, advertisement, social media channels, audio-visual presentations and/or web pages. These photos and videos are exclusively for public information and the promotion of North York Arts and its partner organizations.

I give North York Arts permission to take and use video or photos for inclusion in public information and promotional material produced by North York Arts. I give permission for my image to be taken by professional media representatives to be published as news of program coverage, and waive any rights of compensation or ownership thereto.
Photo/Release Form *

Yes No
Signature *

Participant or Parent/Guardian for participants under 18 Clear
Date *

Month Day Year
Date
Would you like to subscribe to our monthly e-newsletter? You will receive updates about upcoming NYA programming, news, and community updates.

Yes! I'd like to subscribe.
Personal Information and Privacy Act (PIPA) Statement

We collect only the personal information that we need for the purposes of providing services to our clients. We protect personal information in a manner appropriate for the sensitivity of the information. We make every reasonable effort to prevent any loss, misuse, disclosure or modification of personal information, as well as any unauthorized access to personal information
Should be Empty:

Intake Form Around Art & Land

SECTION 2: CONTACT INFORMATION

Emergency Contact

Section 3: PROGRAM QUESTIONS

SECTION 4: OUTREACH

SECTION 5: DATA COLLECTION -Optional

SECTION 6: SUBMISSION