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  • ELYCA PROGRAM REGISTRATION FORM

  • Thank you for your interest in participating in the Empowering Leadership in Youth through Community Action (ELYCA) program. 

    The ELYCA program is one of the youths' community initiatives projects at Action for Healthy Communities Society of Alberta (AHC). This initiative is funded by Canada Service Corps.

    The program aims to engage youth from equity-deserving groups in civic engagement and community service through implementing youth-led initiatives. To do this the program provides tools, resources, and guidance to assist youth in developing leadership skills and expanding their social network while contributing to social change in their interested social issues. 

    We encourage youth from equity deserving groups to apply, these include but are not limited to: Indigenous, Newcomer, Racialized, 2SLGBTQIA+ and youth from low-income communities.

    If you require any specific supports or accommodations please reach out to us at, rayyah.sempala@a4hc.ca or pravatika.rai@a4hc.ca

     

  • Part 1:Personal Information

  • NOTIFICATION OF COLLECTION OF PERSONAL INFORMATION 

    The Personal Information that you provide to Action for Healthy Communities (AHC) during the registration process, during the course of participation in any programs or services is collected, used, and disclosed for the purposes of assessing eligibility for programs and services, providing services, ensuring a safe and secure environment for all our participants, supporting Employee education and for internal management purposes. Limited information may also be provided, according to existing funding and/or information sharing agreements, for the purpose of carrying out programs, activities, or policies (e.g., research, statistical analysis, etc.) or for receiving provincial and/or federal funding. For more information, please contact the AHC Privacy Officer at vlada.savitskaia@a4hc.ca. 

    Protecting Personal Information
    AHC is committed to safeguarding the personal information provided by our clients. The personal information that you provide is collected for AHC purposes such as activity enrolment, emergency contacts, AHC program assessment, funding reports and quality enhancement. Your collected information is not shared outside AHC without first obtaining your consent, unless AHC is obliged or permitted by law to disclose it. AHC keeps your information confidential, your information will be treated with the utmost care and discarded appropriately when it is no longer needed according to AHC retention guidelines and applicable standards.

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  • Part 2

    Participation Details

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    Consent for Use of Photographs, Videos, and Testimonials

    I hereby consent to Action for Healthy Communities photographing or filming myself, my child, my project, or my child’s project, as well as collecting testimonials. I understand that these photos, videos, and testimonials may be used for program evaluation, reports to donors, promotional purposes, and across AHC's marketing materials, including flyers, brochures, websites, social media, and other platforms. I acknowledge that I will not receive compensation for the use of these materials, and that all photos, videos, testimonials, and related content remain the property of AHC and its partners.

    I understand that I can withdraw my consent at any time by contacting vlada.savitskaia@a4hc.ca.

     

  • Informed consent and waiver Consent (Consent should be made by the parent/guardian If the participant is under 18 years old)

    I acknowledge that I am aware of, and accept the inherent physical risks and the other possible risks, dangers, and hazards associated with being a participant. These risks include but are not limited to all manner of injuries, broken, damaged or lost belongings and transmission of diseases (including Covid-19) in various ways and types from contact with other participants. I understand that Action for Healthy Communities (AHC) (employees, facilitators, and volunteers) are not responsible for any injury, loss or damage of any kind sustained by participants during the program or after the program day has ended. I understand that the rules and regulations are designed for the safety and protection of participants and hereby agree to follow /inform (my child) of the importance of abiding by the rules and regulations set down by Action for Healthy Communities.

  • Type your name below as a signature

    By typing my full name I declare that I've carefully read, understood and agreed to the contents of the above (The form should be signed by parent or guardian of the youth if the youth are under 18 years old)

  • Parent or Guardian name:

    By typing my full name I declare that I've carefully read, understood and agreed to the contents of the above (A Parent or Guardian of the youth should type their name below if the youth are under 18 years old)

  • Thank you for your interest in the ELYCA program, unfortunately at this time you are not eligible for the program. Please email us at rayyah.sempala@a4hc.ca for more information and other options for seed-grant funding that we have! 

    We have comprehensive community development unit that offers seed-grant funding for some particpants not eligble for ELYCA! For more information on this programming please email, communitydevelopment@a4hc.ca or call 780.944.4687, Ext.241.

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