Student application form

(SMU REB File #10-118)

In order to participate in the Youth Initiative you must:

be a person with a disability
attend a post secondary institution in Canada
be willing to participate in evlauation activities

Please fillout the information below or download the application form and return to Janice Stevens: janice.stevens@smu.ca or fax: 1.902.496.8122

First name:

Last name:

Email:

Birth year:

Gender:       Male Female

Home province:

Are you willing to disclose that you have a disability?

         If yes, what is the nature of your disability?

Name of post secondary institution you are attending?

         Post secondary institution province?

Have you contacted a faculty member to participate in the Youth Initiative?

         If yes, have they agreed to participate?

Have you contacted other support professionals at your institution about the project?

         If yes, who did you contact?

Are you willing to participate in evaluation activities?

Do you have access to a headset or lapel microphone?

How did you find out about the Youth Initiative?

Why do you want to participate in the Youth Initiative?

Please note: you will receive an email by the next business day to confirm your application has been received. Thank You.

The information collected below will be kept confidential and used to ensure Youth Initiative participants meet the criteria defined by Canada’s Social Development Partnerships Program and the Project Team. The selection process will ensure all five Canadian regions and a variety of disability types are represented. No names will be used when reporting and at the conclusion of the Youth Initiative all information collected below
will be destroyed.