Children’s Referral Form Youth Information(Please provide details to the best of your knowledge. Information provided is confidential.)Youths Full Name(Required) First Last Gender Youths Pronouns Does youth identify as First Nations, Metis, or Inuit? Yes No Unsure Date of Birth(Required) MM slash DD slash YYYY Has this youth attended one of our workshops in the past? Yes No If yes, which workshop? School Current Grade(Required) Youth Resides in(Required)Grande PrairieCounty of Grande PrairieMD of GreenviewOtherRegistrant InformationI am filling out this registration form as the(Required) Youth Parent / Guardian Other Is the youth aware of this registration and in agreement to the program?(Required) Yes No Is parent/guardian aware of registration and in agreement to the program?(Required)Please make parents aware the registration has been made for their child. Yes No Name of Parent/Guardian(Required) First Last Parent/Guardian Phone NumberParent/Guardian Email Your Name (If different than parent/guardian) First Last Your relationship to Youth Your Email Would you like to add emergency contact information?(Required) Yes No Emergency Contact InformationEmergency Contact Name First Last Relationship to Youth Emergency Contact Primary Phone NumberThis is my Landline Cell Phone Other Additional InformationHow did you hear about The Gryphon/Phoenix Group?(Required) Please list any of the youth's strengths or challenges that you think would be beneficial for us to know about?Does the youth have any medical or mental health concerns that we should know about?Please provide any information on the youth's dietary restrictions or allergies:Are there any people that the youth should not be in contact with? (Past issues, severe negative influence etc.)Has the youth experienced challenges in a group setting? If yes, please explain.(Required)Policy AcknowledgementProgramming Policy(Required) I agree to the programming policy.There may be situations where a youth is asked to leave programming and the parent/caregiver are required to pick them up. These situations can include but are not limited to: – Aggressive or abusive behavior towards staff or other participants including, but not limited to: name calling, harassment, vulgar or inappropriate behavior, physical altercations, etc. – Refusing to participate in the workshops activities or cause disruptions in the programming for the rest of the individuals. – Possession or use of cell phones and tablets during workshop hours. – Unwillingness to follow the rules or group guidelines that leads to the disruption of the workshop. – Any other situation where program staff feel it is in the best interest of the individual or group.Confidentiality I have read the confidentiality policy.All information provided in this referral form is used to determine suitability of the youth for our programming and maintained in accordance with Alberta’s Personal Information Protection Act (PIPA) and other applicable laws. Personal information will not be used or disclosed without consent from the participant, or parent/caregiver where applicable, except in the following situations: – The youth discloses allegations of abuse or neglect. – The youth discloses intention to harm themself or others. – The information is requested by a law enforcement official or court. (Please provide details to the best of your knowledge. Information provided is confidential.)
