📝 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
Nov 23: Deeper Gratitude
Dec 7: For Giving
Dec 10: Wheel of Life, Deep Exploration
Jan 14: Vision Board
Jan 19: Wisdom
If you register by Mon Dec 5, we can physically mail you the worksheet handout. Alternative, you can use your notebook to follow along.
Yes, please mail it to me
No, thanks
Please confirm your mailing address
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?
*
Yes
No
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
Submit
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