Youth in Extended Society Care Mentorship Registration

Personal Information

First Name

Last Name

Current Address

City

Province

Postal Code

Age

Cell Phone #

Email Address

My preferred form of communication:

Cell Phone #

Email Address

*Please note: The majority of communication about the mentorship program will be sent using your preferred method of communication

Emergency Contact Information

Contact First Name

Contact Last Name

Relationship to you

(i.e. guardian, CAS worker)

Contact Phone #

Contact Email Address

What are your Interests?

Education

Are you in secondary school?

If yes, what grade are you in?

If no, have you graduated from high school?

More About You

Nipissing University and the Crown Ward Mentorship Program is committed to accessibility for persons with disabilities. Please contact us if you have any particular accessibility requirements.
Contact: Crown Ward Mentorship Program, crownwardteam@nipissingu.ca or call 474-3450 ext. 4241.

Please indicate if you have any dietary restrictions and/or allergies

Please specify in the box provided your dietary restrictions and/or allergies

Consent

All participants must read, sign and submit the Activities Authorization Consent Form and Waiver provided HERE. If a participant is under 18 years old a guardian and/or CAS worker must also sign. This form can be submitted by email to crownwardteam@nipissingu.ca or in person on the first day of participation in the mentorship program.

Please sign your full name in the box below

By signing your name above, you have will have successfully registered as a student participant in this program. You clearly understand what you are agreeing to do, you have read and understood this registration form, and have had any questions, concerns or complaints answered to your satisfaction.