CLI Participant Registration Form Logo
  • Registration Form

    Community Leadership Initiative
  • Thank you for your interest in joining CLI! Please complete this registration form fully. A response is required to each question. If you cannot answer one of the questions, please insert ‘N/A’ in the textbox. 

  • About You

    Thank you for applying for CLI. If any of this information is not applicable to you, please indicate so in your response.
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  • Please note, you must reside in Metro Vancouver to be eligible for the CLI program.

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  • Demographics

    This information is required by the funder of the program. Please answer these questions to the best of your ability.
  • *For the question below, please report on the ‘completed’ level of education. For example, if you are a current High School student, you would indicate ‘Elementary School'.

  • Residential Information

    Thank you for applying for CLI. If any of this information is not applicable to you, please indicate so in your response.

  • Medical Information

    Thank you for applying for CLI. If any of this information is not applicable to you, please indicate so in your response.
  • *It is important for CLI staff to understand your medical needs in case of emergency.

  • Consent To Service

    Thank you for applying for CLI. If any of this information is not applicable to you, please indicate so in your response.
  • I understand that information obtained during the course of service is privileged and confidential and may not be released without my written consent, except in the following situations:

    • When it is necessary to disclose the information to the personnel of S.U.C.C.E.S.S., funder, regulatory body or accreditation agency who are authorized to receive such information in the course of their duties;
    • When it is required by law or by an order of court; and
    • When there is reasonable ground to believe that such release will prevent me from harming myself or other people, or being harmed.

    All records are the confidential property of S.U.C.C.E.S.S. and are retained in a secure and protected environment, which can only be accessed by key personnel. S.U.C.C.E.S.S. is in compliance with the Personal Information Protection and Electronic Documents Act (PIPEDA). All data collected from me is used only to: assist S.U.C.C.E.S.S.’s worker in providing service for me; identify me as an eligible client; provide anonymous general statistics to related funders and in presentation to the public; as well as to help conduct general analysis for quality assurance.

    I acknowledge that the use of computers may be involved in this program and

    I give consent to participate in electronic communication with staff members and other group members. This may include the use of phone calls, text messages, emails, or video conference calls to assist in the development of group members.

    I give permission for my youth to go home by themselves after the program. I understand staff are not expected to provide childminding services.

    I understand that if I have any concerns regarding the program or staff, I can contact the staff-in-charge. I hereby give my permission to S.U.C.C.E.S.S. to use photos, a facsimile thereof or electronic image(s) in which I appear during the program. These photos or facsimiles may be reproduced by S.U.C.C.E.S.S. in print materials such as brochures and news articles. Electronic image(s) may be used in media such as the S.U.C.C.E.S.S.S. website, television news items or a video production.

     

    PROTECTION OF PERSONAL INFORMATION POLICY

    S.U.C.C.E.S.S. respects the privacy rights of individuals and is committed to protecting the personal information of S.U.C.C.E.S.S. members, clients, donors, volunteers, and employees.

    In the course of providing service, organizing activities, and managing the Society, S.U.C.C.E.S.S. needs to collect, use and disclose client’s personal information. S.U.C.C.E.S.S. will only do so in strict compliance with the prevailing legislation in order to protect the privacy of personal information.

    S.U.C.C.E.S.S. will obtain consent from individuals when it collects, uses or discloses personal information. Individuals may withdraw consent at any time, subject to legal or contractual restrictions and reasonable notice.

    Any individual who provides S.U.C.C.E.S.S. with personal information should expect that it will be carefully protected and that its use and disclosure is subject to the individual’s consent.

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  • Clear
  • Applicant has signed the form.

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