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YEBO BOYZ Participant Intake Form

Thank you for your interest in YEBO BOYZ, a free cultural arts, dance, wellness, mentorship, and leadership program for Black boys ages 10–15.

This form must be completed by a parent or guardian. The information will help Afiwi Groove School provide a safe, supportive, and culturally affirming experience. Some information may be reported to the funder in aggregate, without identifying individual participants.

Section 1: Participant information

Participant’s first name*

Participant’s last name*

Participant’s age*

Which Durham Region municipality does the participant live in?*

Section 2: Participant goals

What does the participant hope to gain from YEBO BOYZ?*

Build confidence and self-expression

Develop African and Caribbean dance skills

Learn about Black culture and identity

Make new friends

Connect with mentors and positive role models

Develop leadership skills

Improve wellness and emotional expression

Prepare for the youth showcase

Feel more connected to the community

What is one thing the participant hopes to learn or experience through YEBO BOYZ?

Section 3: Parent/guardian information

Parent/guardian full name*

Parent/guardian email address*

Parent/guardian phone number*

Emergency contact name*

Emergency contact phone number*

Emergency contact relationship to participant*

Who is authorized to pick up the participant?*

Section 4: Health and support needs

Does the participant have any allergies, dietary needs, medical needs, or accessibility needs staff should know about?

Is there anything that would help the participant feel safe, welcomed, and supported?

Section 5:How do you feel before starting YEBO BOYZ?

I feel confident expressing myself.*

I feel proud of who I am*

I feel connected to my culture and identity.*

I feel like I belong in my community.*

I feel comfortable participating in dance and the arts.*

I can make friends and work well with others.*

I feel supported by positive adults and mentors.*

I can take on leadership roles.*

I know positive ways to manage my emotions or stress.*

I feel safe and supported in spaces created for me.*

What are you most looking forward to experiencing through YEBO BOYZ?

What would help you feel comfortable, welcomed, and supported in the program?

Section 6: Consent

Parent/guardian participation consent*

I confirm that I am the participant’s parent or legal guardian and give permission for the participant to participate in YEBO BOYZ.

Program evaluation consent*

I understand that attendance and participant feedback may be collected for program evaluation and reported to the funder in aggregate. Individual identifying information will not be included in public reports.

Photo/video consent

I agree

I do not agree

Afiwi Groove School

Afiwi Groove School is a federally incorporated nonprofit community arts and culture organization serving Durham Region through African and Caribbean dance, drumming, storytelling, youth programs, seniors programming, and community arts initiatives.

info@afiwigroove.com

1895 Clements Rd #102, Pickering, ON L1W 3V5

Phone: (647) 393-8035

Terms & Conditions

Refund Policy

Charitable Trusteeship Partner

Afiwi operates in partnership with Community Development Council Durham (CDCD) under a formal trusteeship agreement. Afiwi remains an independent non-profit organization and is not itself a registered charity.

CDCD is a registered Canadian charity: 130979826RR0001. Official donation receipts may be issued by CDCD for eligible gifts processed under the partnership agreement.

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