📝 Registration
Email
*
example@example.com
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Have you registered for a Success Accelerator workshop/program in the past?
*
Please Select
Yes
No
Note: If you haven't completed a registration form before, please select "No". If you're registering for multiple, just select "No" for the first one.
Preferred Name
If it differs from your legal name
Date of Birth
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred by (please include the organization and name of the person)
Email of referral person
example@example.com
Which of the following do you identify with?
*
Involved with the Justice System (means a history with the criminal justice system and/or agencies such as John Howard or Elizabeth Fry)
Experienced homelessness
Experienced mental illness (either self-identify or clinically diagnosed)
Experienced trauma
Gender-Based, Intimate Partner and Family Violence
Indigenous
In or are leaving the care of the Children's Aid Society
LGBTQIA2S+
Low Income OR on Social Assistance (Low income means an individual who ears less than $20,778 per year or $41,198 per year for a family of four, Social Assistance includes government income subsidy including EI, OW, ODSP, or Basic Needs Allowance)
Newcomer (means individuals who have resided in Canada for less than five years)
Person with a Disability (this includes any physical disability, mental impairment, developmental disability or learning disability)
Racialized (means groups of people who might experience unequal or different treatment on the basis of race, ethnicity, language, religion or culture)
Refugees
Single parent (yourself)
Substance abuse/addiction
Unemployed
None of the above
Other
What is your highest level of education?
*
Some High School
High School/GED
Some Post-Secondary
College
Bachelor's Degree
Graduate Degree
Other
Which work/program did you want to register for?
*
Please Select
Finish the Year Intentionally 2023
Emotional Intelligence
Positive Intelligence: Mental Fitness
Wellness Workshop
Life Coaching/Counselling/Mentor
MasterClass Club
Benefits Webinar (Recorded)
Life You Want Program
Which Wellness Workshop would you like?
Please Select
Forgiveness
Gratitude
Mindfulness
Which EQi-2.0 assessment report type would you like? (The language for each respective report would be geared towards either workplace or school setting)
*
The Workplace Report
The Higher Ed Comprehensive Report
I need help figuring out which one is right for me
Other
As you explore the EQ-i 2.0, think about how active it is in your life. Check the appropriate box. Low, Mid-Range, or High for each competency. Low activity does not necessarily mean low skills, and high does not necessarily mean refined ability.
*
Low
Mid
High
Self-Perception
Self-Expression
Interpersonal
Decision Making
Stress Management
Well-Being (Happiness)
Do you have access to a smart phone with internet access?
*
Yes I do
Sort of, I need to share it with someone
No I don't
Other
What interested you about this coaching/counselling opportunity?
*
What is it that you really, really want to create in your life, and why?
*
What is holding you back from getting there?
*
Fear, habits, insecurities, time, people, etc.
How would your life feel and what will it look like when you get there?
*
List your top 3 most important goals that will support moving towards your desired future.
*
Specifically which personal qualities, habits, and behaviors do you want to develop to help you reach these goals?
*
What are you willing to commit to in order for you to realize your goal?
*
Is there anything else you'd like me to know about you?
What questions or concerns do you have?
Would you like to join for lunch
*
Yes please
No, thanks
Do you have dietary restrictions?
Would you request for reimbursement of transportation expenses? (eg. public transit fare)
*
No thanks, please use the funds towards others that need it.
Yes, it would really help me out.
How much reimbursement are you requesting?
Please note, we have a small budget for this, and you will not be reimbursed unless approved in writing by email.
Please confirm your mailing address for the materials you need associated to this program
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Setting intention, what are you hoping to get out of attending this workshop/program?
*
Have you taken any workshop related to this topic in the past?
*
Never
Yup, just one
Yup, several in fact
Other
Are you committed to attending the program and showing up for yourself? (This means completing the assignments, attending all the sessions, and always be in communication if you're unable to)
*
Yes
Hmm, maybe
No
Other
Which MasterClass(es) are you most looking forward to
You can share the name of the instructor, topic, or the specific class
If selected, which of the MasterClass topics would you like to join a discussion in?
All
Communication
Creativity
Diversity, Equity, and Inclusion
People & Culture
Productivity
Leadership
Personal Growth
Strategy
Teamwork
Wellbeing
None, I am not interested in group discussion on these classes
Other
Do you agree to completing reports to share how you've benefitted from accessing MasterClass every 4 months?
Yes
No
Maybe, I have some questions
Other
By continuing with this application, you agree to the following terms and conditions:
If you indicated that you are referred by an organization or someone, we may share the attendance of your participation in our program(s) with the organization or person as indicated https://www.successaccelerator.ca/terms-and-conditions AND https://www.successaccelerator.ca/media-release
Please confirm
*
Yes, I have read and agree to the statement set out above and the Terms & Conditions.
Yes, I'd like to receive communication and be the first to know what's going on at Success Accelerator!
Signature
Clear
Is Client?
*
Yes
Submit
What is one thing you'd like to accomplish this year?
Describe it in as much details as you could. By making this declaration, you're already the top 20% of the general population.
Should be Empty: