Y Mind Information Request
Complete the form below to have a facilitator contact you.
Participant's Name
*
First Name
Last Name
What is the age range of the listed participant?
*
13-17 years of age
18-30 years of age
Parent/Guardian's Name
*
First Name
Last Name
Parent/Guardian's Email
*
example@example.com
Parent/Guardian's Phone Number
*
Please enter a valid phone number.
Participant's Email
*
example@example.com
Participant's Phone Number
*
Please enter a valid phone number.
Which region of Alberta are you from?
*
Red Deer region
Edmonton region
Grande Prairie region
Wood Buffalo region
Other
Are you able to attend weekly sessions between September 12–October 30?
*
Yes
No
Will your teen be between 13–18 years of age as of September 2022?
*
Yes
No
Do you have a reliable method of transportation to attend program?
*
Yes
No
If not, please identify the barrier you have?
*
How did you hear about Y Mind?
*
Social media
Website ad
Billboard
Newspaper/magazine
Radio
School
YMCA website
Word of mouth
Other
Please verify that you are human
*
Submit
Should be Empty: