Youth Education Supports Program Long Intake Form
Intake Date
*
-
Month
-
Day
Year
Date
Basic Demographics
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
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Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Personal Cell:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender Identity:
*
Male
Female
Non-binary
Transgender
Gender queer
Gender questioning
Gender fluid
Two-Spirit
Agender
Intersex
Does not wish to answer
Pronouns:
She/Her/Hers
He/Him/His
They/Them/Theirs
Does not wish to answer
Do you self-identify with any of the following population groups:
*
Black or racialized
Youth with disabilities
Youth from low-income households
Youth underserved or marginalized
Youth living in rural/remote or northern areas
Youth in care or aging out of care
Youth experiencing or at-risk of homelessness
Youth identifying as 2SLGBTQIA+
Youth from official language minority communities
Newcomer (under 5 years)
Immigrant
Does not wish to answer
Indigenous:
First Nation
Metis
Inuit
Unaffiliated
Does not wish to answer
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Referral Source:
*
Advertisement
Children Services
Employer
Family / friend
School
Self
Social Service Agency
Other Participants
Government Agency
YMCA
Other:
Parent/ Guardian Information
Parent 1’s
*
Parent 2’s :
Guardian’s :
Contact Restrictions:
Are you currently involved with child and family services?
*
Yes
No
Emergency Contact:
*
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Personal Information
What is the best way to contact you?
*
Telephone (home number)
Telephone (cell number)
Text message
Email
Where are you currently living?
With your parents/guardian
Foster Home
Group Home
On your own
Other:
Are you currently registered in school?
*
Yes
No
School name:
*
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What is your current grade level?
*
GR 10 (end of year)
GR 11
GR 12
First Year PSE
Doyou want to graduate?
Yes
No
Unknown
Do you want to attend post-secondary (e.g.,college, etc.)?
*
Yes
No
Unknown
Would you be the first person in your immediate family to attend post-secondary?
*
Yes
No
Unknown
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What are your career goals?
Where would you like to attend post-secondary?
Do you need financial support to attend post-secondary?
*
Yes
No
Unknown
Are there any other factors hindering your ability to complete school?
Yes
No
Unknown
If yes, what are they?
Where would you identify as those factors?
Submit
Should be Empty: