Revolution 4.0 Application Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date of birth* This field is required.
Date
Year
Month
Day
6
Age Group* This field is required.
15 to 19 years old
20 to 24 years old
25 to 30 years old
31+ years old
7
Gender* This field is required.
Female
Male
Trans
Intersex
Two-spirited
Other
Prefer not to say
8
How did you hear about the Friendship Revolution 4.0?* This field is required.
9
If you were referred to this project by someone, please specify who it was:
10
Highest Level of Education Completed* This field is required.
Elementary School
High School (or equivalent)
No certificate/Diploma/Degree
Apprenticeship or Trades Certificate/ Diploma
Cegep/College/Other non-university certificate/Diploma
University Certificate/ Diploma/ Degree at bachelor level or above
Other
11
What is your language preference?* This field is required.
EnglishFrench
12
Are you a member of a Visible Minority or Racialized Group?* This field is required.
YESNO
13
Please select which Visible Minority or Racialized Group you identify with:
Arab
Black
Chinese
Filipino
Japanese
Korean
Latin American
South Asian
Southeast Asian
West Asian
Other
Mutliple Visible Minorities
14
Do you have a disability?* This field is required.
YESNO
15
Do you have any specific accessibility needs?
16
If there is something specific that may trigger you, what is it? And what can we do to help and support you?
17
Do you identify as being indigenous?* This field is required.
YESNO
18
Which group do you identify with:
First Nation
Metis
Inuit
Other
19
Do you identify as being LGBTQ2+?* This field is required.
Yes
No
Prefer not to say
20
Have you moved to Canada within the past 5 years?* This field is required.
YESNO
21
Which day(s) of the week would work best for you?* This field is required.
Monday
Tuesday
Wednesday
Thursday
Sunday
22
Are there any months or times of the year that you will NOT be available?
23
Which time(s) of the day would work best for you?* This field is required.
Morning
Afternoon
Evening
24
Which of these types of projects are you most interested in participating in?* This field is required.
Working with Youth
Inclusion in the Workplace
Social Inclusion
Inclusion in Sports
Inclusion through the arts (ex. creative writing, painting and drawing, drama, etc)
Teaching/Public speaking about inclusion
Other
25
How would you say you best express yourself?* This field is required.
Verbally (through speech)
Through writing
Assistive Technology
Sign language
Spelling to Communicate
Other
26
Please share which of these you would feel comfortable doing?* This field is required.
Public Speaking
Sharing personal stories
Being on camera
Talking about mental health
Showcasing talents
Working with children/youth
27
List one fun fact about yourself that you can share with the group (for example: I know how to juggle!)* This field is required.
28
T-shirt/Sweatshirt size:* This field is required.
XS
S
M
L
XL
XXL
29
Please note that the Friendship Revolution is a serious commitment of 120 hours of participation in this project. I am ready to commit to and contribute to my team in the form of meetings, activities, and events. I will do my best to share ideas and collaborate, whether in-person or online. I understand that my team will be counting on me to help our project be as successful as it can be, with my full participation.* This field is required.
I understand and I agree
Other
30
I give consent for my contact information to be shared with the Government of Canada for reporting purposes. * This field is required.
I understand and I agree
I understand and I disagree
31
Signature* This field is required.
Should be Empty: