Application: EmpowerPen Writing Program
We are accepting applicants to join us in transformative Writing MasterClass https://www.successaccelerator.ca/empowerpen Thank you 💙
Email
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example@example.com
Name
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First Name
Last Name
Have you attended a Success Accelerator workshop/program in the past?
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Please Select
Yes
No
Preferred Name
Date of Birth
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Referred by (please include the organization and name of the person)
Which of the following do you identify with?
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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/ 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 (self)
Substance abuse/addiction
Unemployed
None of the above
Other
What is your highest level of education?
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Some High School
High School/GED
Some Post-Secondary
College
Bachelor's Degree
Graduate Degree
Other
What do you hope to get out of participating in this program?
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
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Yes, I have read and agree to the statement set out above and the Terms & Conditions.
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