YAST - Young Adult Social Virtual Group - Intake Registration Form for In-Person Group at Nanaimo CDC

YAST - In-Person Social Group including occasional Community Events

Please complete this registration intake form.

*Young Adult Social Time group is meant for individuals (18 to 28 years old) who are already able to access the community independently and who can participate in the group without 1:1 support, and lives in the Nanaimo/Ladysmith area. Welcome for surrounding areas as well, please not group activities will be a mix of on site at the Nanaimo Child Development Centre in the Community Room and occasional community outings, happening on Monday evenings from 6 pm to 8 pm.

Once your registration is received one of the staff members from the Young Adult Social Time group will be in contact with you, to confirm registration. The Facilitators for YAST are Rebecca and Kai and our Coordinator is Kimberlee. They look forward to meeting you soon.

If you have any questions, please call program coordinator Kimberlee @ 250-618-5640 or Kimberlee@nanaimocdc.com.

This group is supported by The Allen and Loreen Vandekerkhove Family Foundation & Nanaimo Child Development Centre.

Thank you for completing all questions on this intake form. Information will be used only for the purposes of this group and not shared outside the YAST staff and organizers.

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* 1. Please tell us about yourself:

First & Last Name *

Birth Date

Address *

City/Town

Postal Code *

Email Address *

Phone Number (home) *

Cell Number

Diagnoses, if any: *

Allergies, if any: *

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* 2. Any Medical concerns that could be present while you are attending group, if yes please describe so staff can support you in best way possible?

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* 3. Your Hobbies or Interests? (What do you like to do in your free time)

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* 4. Do you need help with any of the following? (Please check all that apply - this info will be for public outings)

Wandering

Responding positively to Authority

Physical boundaries

Following group ground rules

Traveling on local Transit

Being in public settings - community outings

Toileting

None of the above

Need help with: (something not listed above)

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* 5. Please check any of the following that affects you?

Large groups of people / crowds

Loud noises - Loud Environments

Smells

Lighting

None of the above

Something that is not mentioned above that affects you when with others?

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* 6. What do you hope will happen for you by attending this group sessions:

Make new friends

Learn new things

Have fun

Learn more about our community

Or I'd like to:

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* 7. Emergency Contact info: (Contact person over the age of 18 in case of emergency)

Name

Relationship to you

Address

City/Town

Phone Number

Email Address

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* 8. Additional Person to contact with program info if unable to contact you, or you'd also like to receive email notifications?

Name

Phone Number

Email Address

Relationship to you:

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* 9. How did you find out about Young Adult Social Time?

From a community Agency (Please list in comment box which one)

Facebook

Individual - Family Member

Individual - Support worker

Individual - Friend

Which Agency did you learn about group from:

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* 1. Please tell us about yourself:

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* 2. Any Medical concerns that could be present while you are attending group, if yes please describe so staff can support you in best way possible?

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* 3. Your Hobbies or Interests? (What do you like to do in your free time)

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* 4. Do you need help with any of the following? (Please check all that apply - this info will be for public outings)

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* 5. Please check any of the following that affects you?

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* 6. What do you hope will happen for you by attending this group sessions:

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* 7. Emergency Contact info: (Contact person over the age of 18 in case of emergency)

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* 8. Additional Person to contact with program info if unable to contact you, or you'd also like to receive email notifications?

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* 9. How did you find out about Young Adult Social Time?

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* 10. Thank you for completing all questions on this form, if there is anything else you'd like us to know please tell us in comment box below :-)