Building Power Application Form

1
Staff Email
example@example.com
2
Name* This field is required.
First Name
Last Name
3
Preferred Name
What name would you like us to use when we address you?
4
Pronouns* This field is required.
example: he/him, she/her, they/them
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Email* This field is required.
example@example.com
7
City
8
Province* This field is required.
Please Select
Please Select

Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
9
Postal Code* This field is required.
10
Emergency Contact
First Name
Last Name
11
RelationWho is this person to you?
12
Phone Number
Please enter a valid phone number.
13
Email
example@example.com
14
What issues are important to you? It may help to think about your personal advocacy statement by completing the sentence below:* This field is required.
"When I think about __________ (topic, issue, or policy I would like to change), I feel __________ because __________."
15
How have you put these interests into action in your school or community through a project or community based activity?* This field is required.
16
Why are you interested in this program?* This field is required.
17
How do you see this program fitting into your future goals?* This field is required.
18
What do you hope to get from this program?
learn about social justice issues affecting 2SLGBTQ+ BIPOC young people
connections to 2SLGBTQ+ BIPOC young people serving community organizations
improve my advocacy and leadership skills
learn about different career options or career path relating to 2SLGBTQ+ BIPOC youth advocacy
learn different ways to support and advocate for issues affecting 2SLGBTQ+ BIPOC young people
19
Do you identify as Black, Indigenous, or a Youth of Colour?
Black
Indigenous
Youth of Colour
Unsure
Prefer Not to Say
Other
20
Are you a student enrolled in high school or post secondary program?* This field is required.
Please Select
Please Select
Yes, High School.
Yes, Post Secondary
No
21
Do you identify as 2SLGBTQ+ or as an ally?
2SLGBTQ
Ally
Unsure
Prefer Not to Say
22
Do you think you will be able to commit to attending this program once weekly for several months?* This field is required.
Please Select
Please Select
Yes
No
Not sure but I'm still interested
23
How old are you?* This field is required.
24
How did you hear about us?* This field is required.
25
The personal information on this form is collected under the authority of the City of Toronto Act, S.O. 2006, Chapter 11, Schedule A, s. 136 (b) & (c). Personal information is used for program registration and reporting purposes only. The 519 will not trade personal information with any other organizations. Questions about this collection can be directed to the Privacy Officer at The 519, 519 Church Street, Toronto, ON, M4Y 2C9 by e-mail at Privacy@The519.org or by phone at 416-392-6874.
26
Date* This field is required.
enter the date you are submitting the form
Month
Day
Year
Should be Empty: