RISE Program Intake & Participation Form

R.I.S.E PROGRAM

Refining Hope. Igniting Purpose. Strengthening Futures
Description
This form helps us understand each participants goals, strengths, and areas where support may be needed so we can provide the best possible mentorship and learning experience.
I want to register as a*

MentorMentee
SECTION 1 Participant Information
Full Name*

First NameLast Name
Date of Birth*
Age*
Gender Identity

FemaleMaleNon-binaryPrefer not to sayOther
School / Institution Name*
Grade Level (if applicable)
City / Community*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Name (if different)
Primary Language Spoken*
Additional Languages
SECTION 2 Parent / Guardian Information (If Participant Under 18)
Parent / Guardian Full Name*

First NameLast Name
Relationship to Participant*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 3 Participant Background
Which of the following best describes you? (Optional)

IndigenousBlack / African descentRacialized youthNewcomer / Immigrant youthRefugee youthYouth living in low-income householdYouth in care / foster systemNone of the abovePrefer not to sayOther
SECTION 4 Education & Career Interests
What are your current educational goals?*

Graduate high schoolAttend college / universityEnter skilled tradesStart a businessUnsure / exploring options
What careers interest you most?*

Business / EntrepreneurshipTechnologyHealth CareSkilled TradesArts / Creative industriesCommunity leadershipPublic service
What subjects do you enjoy most?*

MathScienceEnglish / Language ArtsSocial StudiesArtsTechnology
Which areas do you want support with?*

Homework / academic successStudy habitsLeadership skillsCareer explorationConfidence buildingCommunication skillsPublic speaking
SECTION 5 Personal Development & Leadership
What motivated you to apply for the R.I.S.E Program?*
What personal goals would you like to achieve through this program?*
Which leadership skills would you like to develop?*

ConfidenceDecision makingConflict resolutionTeamworkCommunicationCommunity leadership
SECTION 6 Wellbeing Check-In
Over the past month, how have you felt?*
Confidence in yourself*

Very confidentSomewhat confidentNot confident
Stress related to school or life*

LowModerateHigh
Do you currently have supportive adults or mentors in your life?*

YesSomeNot really
Would you be interested in support in any of the following areas?*

MentorshipMental wellbeing coachingLife skills developmentLeadership trainingCareer guidance
SECTION 7 Youth Interests & Engagement
Which activities interest you most?*

Leadership workshopsEntrepreneurship trainingCommunity service projectsCultural learning activitiesPublic speakingSocial media campaignsYouth debates
Would you be interested in becoming a Youth Ambassador for your school or community?*

YesMaybeNot sure yet
SECTION 8 Technology Access
Do you have reliable internet access at home?*

YesNo
Do you have access to a laptop or computer?*

YesNo
How comfortable are you using technology for learning?*

Very comfortableSomewhat comfortableNeed help
SECTION 9 Program Commitment
The R.I.S.E Program runs in alignment with the school calendar and includes: Leadership workshops, Mentorship sessions, Youth empowerment activities, Community engagement opportunities*
This program runs with the school academic Calendar. Each semester the program runs for 12 weeks. To remain active as a member of the program and to ensure that you continue to receive services under the program you MUST attend 3 out of 4 programs each month.

Yes, This is easyNo, this is Not PossibleYes, I can try, However I have special situationNo, I would need major assistance to keep up with this
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MENTOR REGISTRATION FORM

WE NEED YOU
Are You an EL Shama Cares Staff or Volunteers?*

YesNo
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- Name*
  
  PrefixFirst NameLast Name
- E-mail Id*
  example@example.com
- Contact Number*
  Please enter a valid mobile no.
- Communication Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Emergency Contact
- Name
  
  First NameLast Name
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Organization*
  Current Organization
- Occupation*
- Sector*
- Profession*
- Designation*
  Current Designation
- Area of Expertise*
- Education Qualifications*
- About Me-A Short Description*
- LinkedIn*
  Please enter your LinkedIn URL
- Field of Interest for receiving/giving Mentorship on*
  
  LeadershipWomenprenuerCareer/Education GrowthCareer TransitionSocial Assistance and NavigationSelf EmpowermentElevator Pitchmental wellbeinggraduation coachinglife skills buildingHome WorkOther
- If Other, Please Specify
  Separate by comma
- No. of Hours/Month you can dedicate for this program*
  Only add numeric value
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R.I.S.E PROGRAM

SECTION 1  Participant Information

SECTION 2  Parent / Guardian Information (If Participant Under 18)

SECTION 3  Participant Background

SECTION 4  Education & Career Interests

SECTION 5  Personal Development & Leadership

SECTION 6  Wellbeing Check-In

SECTION 7  Youth Interests & Engagement

SECTION 8  Technology Access

SECTION 9  Program Commitment

MENTOR REGISTRATION FORM

Emergency Contact

SECTION 1 Participant Information

SECTION 2 Parent / Guardian Information (If Participant Under 18)

SECTION 3 Participant Background

SECTION 4 Education & Career Interests

SECTION 5 Personal Development & Leadership

SECTION 6 Wellbeing Check-In

SECTION 7 Youth Interests & Engagement

SECTION 8 Technology Access

SECTION 9 Program Commitment