Project Resiliency Student Application

Name*
First
Email*
YOUR (THE APPLICANT'S) KEY CONTACT INFORMATION:
Name*
First Last
Pronouns
School
Current Grade
Home Address
Street Address Address Line 2 City ZIP / Postal Code
Home Phone
Parent/Guardian Name
First Last
Parent/Guardian Cell Phone Number
Student Date of Birth
Preferred Gender
Why are you attending Project Resiliency?
What support have you accessed in your school or community?
Support can include: programs, people who have directly supported you, technology tools or supportive materials that have been helpful.
Which of the following match your circumstances?*
- Gifted - Academic Disinterest
- Gifted - Specialized Programming Required
- Chronic Absenteeism/Attendance Problems
- Chronic Health/Illness
- Academic Underachievement (Poor Grades)
- School or Community Disengagement (Not participating in any school/community programs)
- Substance Use
- Mental Health Support Required
- Learning Disability Support Required
- Physical Disability Support Required
- Attending Specialized Program (Sport Training, Acting, Performing Arts, Fine Arts, etc.)
- Just Wanting a Change
- Not sure or None of the Above Apply

I have viewed and understand the schools/programs website and agree to follow the District Code of Conduct. Intentional, unsafe behaviour will result in withdrawal from Project Resiliency.*
- Yes - I agree
- No - I need further information
I will remain on the property of my Project Resiliency school location until dismissal at the end of the day. I understand that I am responsible for my own transportation to and from Project Resiliency.
- Yes, I understand
FULL PARTICIPATION POLICY - Given that within unhealthy cultures, deception (lying) is an active part of the "enabling" process, we will not endorse or perpetuate any form of deception - to oneself or others. Although this can be challenging, we believe that there are no good "secrets".
Statements or information that potentially put your "safety" or the "safety of others" at risk, may be disclosed to protect the safety of yourself and others.
- Yes, I will fully participate in the program or school and understand that information related to "safety" is disclosed as necessary.
- No, I'd like to withdraw my application for another time or when I'm ready.
Comments
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YOUR (THE APPLICANT'S) KEY CONTACT INFORMATION: