Youth Inclusion Initiative Application

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your age:

If you are 16 or 17, you must have parental consent. Please download the form at the bottom of the page.

Current Email address:

Phone Number:

Phone availability:

please detail the contact methods you prefer:

Phone Calls

Texting

All the Above

How best describes your gender?

1. Male 2. Female 3. Prefer Not to Say 4. Prefer to Self-Describe

If you answered #4 above, please describe:

What are your goals and how could this leaning experience help you to reach them?

What one thing you would like to learn from this program and why?

Tell us something interesting about you! Is there anything else you think we should know about you?

Emergency Contact Information

Please list your 'In case of Emergency' contact information

First Name

Last Name

Phone Number:

Relationship to you