Youth Advisory Committee (YAC) Application Form
Personal Details
Name
First Name
Last Name
Date of birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
What languages do you speak?
Which cultural background/s do you identify with?
Do you identify with the LGBTIQA+ community?
Yes
No
Unsure
Have you or your family ever been homeless?
Yes
No
Unsure
What experience do your family members have with a mental illness?
What personal experience do you have with mental illness?
Are you comfortable talking about your mental health journey?
Yes
No
Unsure
Please tell us a bit about yourself! (How do you spend your time, what do you do for fun? work? school?)
Briefly explain why you are interested in becoming a member of the YAC and what you hope to contribute to the committee.
What skills and ideas could you bring to the YAC? (For example, first aid, school leadership groups, sporting teams etc)
Have you been involved with any other organizations or groups? Please tell us about them!
Is there any other relevant information you would like to share?
Provide contact information for two references (e.g., teacher, community leader, or mentor) who can speak to your character and abilities
Rows
Name
Relationship
Phone Number
Email Address
Reference 1
Reference 2
Applicant's Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: