Brotherhood Program Registration

YAAACE GBV THE REBUILD MENS COLLECTIVE FORM
DISCLAIMER

YAAACE is a non-profit organization that heavily relies on various grants from the Provincial and Federal Government, as well as other organizations. The following information requested below will be used for internal reporting measures to help determine the need in our community and obtain additional funding and resources to subsidize the cost for all of our participants with the hopes of making all future programs free of cost. We ask that you answer these questions as accurately as possible.

Please note that all data provided on this form and in research surveys may be shared and collected solely in order to evaluate YAAACE programs and their impact on the community that we serve. You may be contacted for follow up research for a period of up to 2 years following the completion of any of the organizations programs.
PARTICIPANT INFORMATION
Name

First NameMiddle NameLast Name
Have you or your kids registered for a YAAACE program in the last 6 months?
Sex
Preferred Pronouns
Date of Birth

MonthDayYear
Date
Home Address

Street Address

CityProvince

Postal Code
Email
example@gmail.com
Cell Phone #
Format: (000) 000-0000.

Allergies/Medical Information

Rows	Yes	Brief Description
Allergies to food/ medicine
Other medical conditions
None

EMERGENCY CONTACT INFORMATION
Emergency Contact Name

First NameLast Name
Relation to you
Emergency Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Email
example@gmail.com
ADDITIONAL INFORMATION
Ethnicity

Other

Approximate Annual Household Income

Rows	Less than 40k	Between 40-60k	Between 50-80k	Over 80k
Single Income Household
Dual Income Household

Have you or a family member had contact with the Criminal Justice System?
How did you hear about the YAAACE GBV Program (Please select all that apply)

Other
THE REBUILD Collective - Committee Program

This space is for people who have lived experience or witnessed gender-based violence, and who are seeking healing, learning, solidarity, skills-building, advocacy, or connection.
How did you hear about the Committee?

Other
Have you experienced or witnessed gender-based violence (past or present)?
Participation does not require proof or disclosure. It is for support, learning, healing, and/or advocacy.
If you’re comfortable, which of the following forms of GBV have impacted you?
Is your participation in this group likely to put your safety at risk? (e.g., being monitored, controlled, or tracked)
Do you have support in place if any topics bring up difficult feelings (trusted person, counselor, support line, faith support, etc.)?
What engagement approach works best for you? (Select all that apply)

Other
What are you hoping to gain from the committee? (Select any)

Other
Are you able to participate and commit to bi-weekly meetings from June 24th to November 11th?
Please confirm you understand: This is a survivor-centred and ally-supportive space. Confidentiality is required. Safety, dignity, respect, accountability, solidarity, and allyship are core values. Qualified YAAACE staff support will be present at all sessions as an immediate support and resource
RELEASE AND ACKNOWLEDGEMENT
I acknowledge that the registration and demographic data provided within this form will be used for research purposes only. I hereby provide my consent to allow the organization to use this information.
I acknowledge that photographs and video may be taken while participating in YAAACE programming and posted to social media, news releases, publications or archived for future use. I hereby provide my consent to allow the organization to use those images solely for their not-for-profit purposes and waive the right to any and all compensation stemming from the use of these materials.
Individual invoices (where applicable) will be emailed for each program once registration is complete.
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YAAACE GBV THE REBUILD MENS COLLECTIVE FORM

ADDITIONAL INFORMATION

THE REBUILD Collective - Committee Program