Common Ground Participant Registration

A 5-week awareness and empowerment program for female-identifying youth aged 12-18.

Weekly Topics Include:
Consent & Boundaries
Social Media
Gender Based & Dating Violence
Healthy Relationships
Human Trafficking
Safety Planning
Self-Care.

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* 1. Upcoming Common Ground Dates/Locations

Orillia Wednesday April 1st - April 29th

Barrie Wednesday May 20th - June 17th

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* 2. What Location of Common Ground are you interested in?

Barrie

Orillia

Virtual

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* 3. Participant's Full Name

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* 4. Participant's Date of Birth

Date / Time

Date

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* 5. OPTIONAL: Preferred Pronouns

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* 6. Caregiver or Youth Contact Information

Name *

Address

City/Town

Email Address *

Phone Number *

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* 7. Common Ground often has our facility dog(s) present. Are you comfortable with dogs?

Yes

No

Unsure

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* 8. Please list any food allergies or dietary restrictions

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* 9. What is your preferred method of contact?

Phone

Email

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* 10. OPTIONAL: Where did you hear about Common Ground?

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* 11. PLEASE NOTE: You will be contacted by a CYACSM Staff member to confirm dates, time and registration closer to our next start date for your location requested.