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Youth Membership Form 2020
First Name
*
Last Name
*
Address
*
Address 2
City
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State/Province
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Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code
*
Phone
*
Email Address
*
Date of birth
*
+
Age
*
Preferred way to contact
*
Phone
Email
Any
School
*
Grade
*
Allergies/health concerns
*
Emergency Contact
First Name
*
Last Name
*
Relationship to you
*
Phone Number
*
Email Address
*
Eastview Programs involved in 2020/2021
Select Programs involved in this year:
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Torch Club
Girl's Group
Beats
Mural Group
Piano
Skills 4 Success
Muslim Girls Taking Initiative
Digital Arts
Black Empowerment Group (including Black History Month planning group)
Homework Help/Tutoring
Homework Help/Tutoring
Volunteer Experience
How many volunteer hours (estimate) have you completed to date?:
*
Volunteer activities to date:
Would you like to volunteer at Eastview?
*
Yes
No
If yes, what programs would you like to get involved with?
Demographic Information
I identify as:
*
Female
Male
LGBTQ2+
Prefer not to disclose
Not listed, please describe:
Not listed, please describe:
My preferred pronouns are:
*
he/him
she/her
they/them
Not listed, please describe:
Not listed, please describe:
Ethnicity(ies):
*
Black (ex. African, Caribbean, African-Canadian)
East Asian (ex. Chinese, Japanese, Korean)
Latino or Hispanic (ex. Colombian, Cuban, Mexican, Peruvian)
Middle Eastern (ex. Afghan, Iranian, Lebanese, Saudi Arabian, Syrian)
South Asian (ex. Bangladeshi, Indian, Pakistani, Sri Lankan)
Southeast Asian (ex. Filipino, Malaysian, Singaporean, Thai, Vietnamese)
Caucasian (ex. English, Greek, Italian, Portuguese, Russian, Slovakian)
First Nations or Indigenous
Not listed, please describe:
Not listed, please describe:
Language(s) spoken at home:
*
First language that you learned to speak
*
Are you a Newcomer to Canada? *Newcomer: came to Canada within the last 5 years
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Yes
No
Did your parents immigrate to Canada?
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Yes
No
If yes, from where:
If yes, from where:
Do you require any accommodations (physical, mental, communication, etc)?
*
Terms and Conditions
*
You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.
Please sign
*
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