Goderich Youth Collective Leadership Program
Application Form
Name
First Name
Last Name
Pronouns:
Date of birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Allergies
Medical Concerns
Emergency Contact Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Applicant
example: friend, sibling, parent, etc.
Topic of Interest Information
Career(s) you would like to learn more about:
example: doctor, police officer, tattoo artist, entrepreneur.
Skills you'd like to learn or strengthen: (please select all that apply)
Budgeting
General Finances
Stress Management
Teamwork
Goal Setting
Focus
Leadership
Cooking
Nutrition
Exercise/Physical Health
Communication
Relationship Building
Hygiene
Basic First Aid
Organization
General Safety
Emotional Self-Management
Problem Solving
Decision Making
Critical Thinking
Creative Expression
Job Search Skills (Interviews, Resumes, etc)
Time Management
General Mental Health
Other
"I would like to participate in this program because..." (please select all that apply)
I want to make more friends
I want to learn more about resources available to me
I want to learn something new
I want to strengthen certain skills
It sounds fun/interesting
I want to have new experiences
Someone recommended that I apply
Other
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