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Project Black Feather
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Project Resiliency, Alternate Programs, and Project Black Feather Intake Form
Parent/Guardian consent for information sharing, communication and transportation.
Information Sharing Consent approved by guardian.
Information Sharing Consent approved by guardian.
No
Information Sharing Consent approved by guardian.
Yes
Driving Consent approved by guardian.
Driving Consent approved by guardian.
No
Driving Consent approved by guardian.
Yes
General
Program Applying For
Project Resiliency Secondary
Project Resiliency K - 7
Game Ready Fitness Request
Alternate Program Request Choices and or Vanguard
Project Black Feather
Game Ready Fitness Details
*
Person Referring
*
Person Referring Contact Number
*
Person Referring Email
*
*
Name
*
Student Legal First Name
*
Student Legal Last Name
*
Student Preferred/Chosen Name if Different
*
Identified Gender
Male
Female
Transgender
Other
Special Ed Designation
PEN
*
Date of Birth
*
Current Grade Level
Pre-School
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Grad / Adult
N/A
Reason For Request
Reason For Request Other
*
Desired Outcomes (Purpose of Request)
*
Successful Tier 2 and 3 Behavioural and or Mental Health Interventions
*
Unsuccessful Behavioural and or Mental Health Tier 2 and 3 Interventions
*
Catchment School
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Guardian Name 1
*
Guardian Contact Number 1
*
Guardian Email 1
*
*
Guardian Name 2
*
Guardian Contact Number 2
*
Guardian Email 2
*
*
Student Primary Residence
*
Does the Student and Guardian have the same address?
Does the Student and Guardian have the same address?
No
Does the Student and Guardian have the same address?
Yes
Address of Guardian
*
Additional Information
School Counsellor/ Clinician
*
Name of School Administrator
*
Additional Contacts/Community Agencies 1
*
Additional Contact/Community Agencies 2
*
Additional Contact/Community Agencies 3
*
Background Information
Critical School Documentation Confirmations
Cultural Background/Information
*
Family Background/Information
*
ADDITIONAL INFORMATION
*
ADDITIONAL RESTRICTIONS
*
Consent of Information Use
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