Participant Application

Your Information

Personal (Adult or Parent)

Name

Surname*

First Name*

Initial

Address

Apt.#

City/Town

Postal Code

Country of Birth

Year of Arrival in Canada

Phone #

Email*

Date of Birth

Primary Language

You Identify as

Indigenous, Other (optional)

Pronouns

(She/Her; He/Him - optional)

Level of Education and location of institution

(high-school, post-secondary, college, other)

Relationship Status

(Single, Divorced, Widowed, Separated, Married, Common-law)

# of children (if applicable)

Household Information

Total # of people in the household

Housing

(Rent, Own, Living with friends/family)

Do you feel safe in your current housing?

Do you have regular access to food?

Allergies:

Employment Status:

Primary Source of Income

(Full-time, Part-time, Casual, Unemployed, Student)

Monthly Household Income

Personal (Child)

Name

Surname

First name

Initial

Address

Apt.#

City/Town

Postal Code

Country of Birth

Year of Arrival in Canada

Phone

Email

Date of Birth

Primary Language

You Identify as

Indigenous, Other (optional)

Pronouns

(She/Her; He/Him - optional)

Level of Education

# of siblings (if applicable)

Relationship to child (Please Specify)

Emergency Contact Information

Name

Surname

First Name

Initial

Relationship to you:

Phone #

Health and Wellness

Are you currently connected with any healthcare providers, counsellors, or social workers?

Yes No

If yes, who?

Allergies:

Consent

Do you consent to have your child’s picture used for marketing purposes (no personal information, like name, age, etc., will be shared on social media or other marketing)?

Yes No

Do you consent to your information being shared with partner organizations for referrals?

Yes No

Would you like to be contacted about future programs, workshops, or events?

Yes No

Why Proud Pathways?

I confirm that the information provided is true and accurate to the best of my knowledge.

Participant Adult

PLEASE PRINT

Participant Child

Surname

First Name

Initial

Signature

Clear Signature

Date

Guided Journey Coaching provides holistic life coaching services across Winnipeg, Toronto, Vancouver, Calgary, and Ottawa.