Youth Connection Form

Youth's Name *

First and Last Name

Date of Birth *

Month, Date, Year

Age *

Address *

please include if you live in North Battleford, Battleford or a surrounding community.

Contact Information - Phone Number/Email *

Gender Identity *

Male

Female

TransgenderTransgender

Non-binary/non-conforming

Prefer not to respond

Ethnicity *

Indigenous

Metis

Asian

Black/African

Hispanic/Latinx

Caucasian

Other

Prefer not to respond

School *

Elementary

Sakewew High School

John Paul II CollegiateJohn Paul II Collegiate

North Battleford Comprehensive High School

OtherOther

Grade *

Allergies / Medications *

Guardian Name, Relationship and Contact Information (Phone Number/Email) *

Referred By *

Phone *

Email *

Obstacles Youth are Facing *

More Details (if needed)

Involvement with Community Organizations (ex: Boys & Girls Club, Big Brothers Big Sisters of the Battlefords, Community Corrections, Counsellor...) *

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