The Men's Advocacy and Support Initiative

Participant Details:

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Contact

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

How did you hear about this program?

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Participant Consent & Confidentiality Agreement

By submitting this registration form, you acknowledge and consent to the following:

Voluntary Participation – Your participation in the Men’s Advocacy and Support Initiative is completely voluntary. You may withdraw at any time without penalty.

Confidentiality – Group sessions are confidential. Information you share will not be disclosed outside the group except in the circumstances outlined below.
• Facilitators and The Men’s Centre staff are bound by professional confidentiality standards.
• Other participants are asked to respect the privacy of everyone in the group and not share any identifying details outside of sessions.

Limits to Confidentiality – The facilitator is legally required to report information if there is reason to believe that:
• A child or vulnerable adult is at risk of harm;
• You are in imminent danger of harming yourself or another person; or
• The information is required by a valid court order or legal process.

Use of Zoom – Sessions are delivered via the Zoom platform. While we take steps to protect your privacy, absolute confidentiality of online communication cannot be guaranteed.
• You are encouraged to use a private space and your first name only if you prefer.
• Sessions will not be recorded.

Data Privacy – The Men’s Centre collects your registration information solely for program administration and evaluation purposes. Your personal information will be stored securely in Canada and used only by authorized staff for the operation of this program, in accordance with the BC Personal Information Protection Act (PIPA).

Evaluation & Feedback – You may be asked to complete brief anonymous feedback forms to help improve the program. Participation in these evaluations is optional.

Support & Emergencies – If at any time you feel unsafe or in crisis, please contact 911 or VictimLink BC (1-800-563-0808), or visit www.victimlinkbc.ca.

By clicking “Submit,” you confirm that you have read and understood the information above and give your consent to participate in this program.

Terms and Conditions:

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