Project Resiliency Student Application

STUDENT INFO
Name*
First Last
Student Date of Birth
Pronouns
Student email and cell phone #*
School
Current Grade
Home Address
Street Address Address Line 2 City ZIP / Postal Code
Parent/Guardian Name
First Last
Parent/Guardian Cell Phone Number
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
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.
Name
This field is for validation purposes and should be left unchanged.

STUDENT INFO