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CultureLink Youth Services
Youth Membership Registration Form
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* Indicates required question
What Program are you registering for?
*
Tick all that applies
Sankofa Youth Drop In
Sankofa LGBTQ+
Global Roots
Tumbao Dance Crew
Multicultural Club
I don't know
Other:
Required
First Name
*
Your answer
Last Name
*
Your answer
Age
*
Your answer
Preferred pronoun
*
He
She
They
Other:
Grade
Your answer
School
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Date of Arrival in Canada (if you were not born in Canada)
MM
/
DD
/
YYYY
Country of Birth
*
Your answer
Languages Spoken
*
Your answer
Address of residence
*
Your answer
Cell phone number
(123-456-7890)
Your answer
Other Phone Number
(123-456-7890)
Your answer
Email address
Your answer
Facebook / Twitter name
(if any)
Your answer
Best way to contact me is:
*
Tick all that applies
Cell phone
Other phone
Email
Facebook
Twitter
Other:
Required
Immigration Status
*
Conventional Refugee
Refugee Claimant
Permanent Resident
Canadian Citizen
Visa Student
I don't know / I do not wish to answer
Other:
What programs for youths are you interested in?
*
Tick all that applies
Leadership Training
English Conversation Circle
Volunteer Opportunities
Sports / Healthy Living
Gardening
Homework Help
Job Opportunities
Girls Only Group
LGBTQ+ Programs
Other:
Required
How did you hear about CultureLink Youth Services?
*
Presentation at my school
I found a flyer / brochure
My SWIS worker or school teacher
My friend told me about it
Facebook / Twitter
Other:
Required
Do you have any health concerns?
*
(if yes, enter description in "other" box)
No
Yes
Other:
Required
If you are less than 18 years old
Name of Parent / Guardian
Your answer
Contact number of Parent / Guardian
Your answer
Relationship
Your answer
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