Eligibility Check:

Are you 17-26 years old?Do you live in Vancouver/Richmond?Do you identify having Mental Health Barrier?

Signup Form

First Name *
Last Name *
Phone Number *
Phone Number Type *—Please choose an option—Cell PhoneHome PhoneOther
Your Email *
Address *
City *
Postal Code *
Date of Birth *
Gender *—Please choose an option—FemaleMaleThey/ThemPrefer not to say
Do you identify as having a mental health condition? *—Please choose an option—YesNoI'm not sure
If yes to above question, please choose: (Check all that apply)
AnxietyDepressionBipolarSchizophreniaPTSDPsychosisOCD
Do you receive support from: (Check all that apply)
VGH (inpatient/outpatient)UBC (inpatient/outpatient)St. Paul's Hospital (inpatient/outpatient)AACMental Health TeamEPIHUB
Other
Please provide a referral contact name and Agency *
Please provide a referral contact phone number *
By checking the box, you give consent to us contact your referral
Additional concerns or other health conditions:
Where did you hear about Summer Session program *?

Emergency Contact:

Full Name *
Relationship *
Phone *
Email *

Parent Consent and Signature (if under 19)

Please be advised that,
age has registered to SUMMER SESSIONS 2023. OPEN DOOR GROUP organizes and run these social, recreational events for young adult ages 17-26years, who are experiencing mental health issues.

Your signature below indicates that you have been informed of and consent to your minor’s (under the age of 19) participation. No minor will be allowed to participate without a signed consent form
Parent or Guardian: (Print Name)

Signature: (Draw in the box below)

Date:
 

Activities List:
Urban Recreation (Please check all that apply)
Kick Off - June 28July 12July 26Aug 9Wrap Up - Aug 23

Choose from Make It! and/or Outdoor Adventure (Please look at calendar for reference)
Prioritize your top picks from 1-4. (1 being most desirable and 4 being less desirable)
—Please choose an option—JULY Outdoor AdventureJULY Make It!AUGUST Outdoor AdventureAUGUST Make It!
—Please choose an option—JULY Outdoor AdventureJULY Make It!AUGUST Outdoor AdventureAUGUST Make It!
—Please choose an option—JULY Outdoor AdventureJULY Make It!AUGUST Outdoor AdventureAUGUST Make It!
—Please choose an option—JULY Outdoor AdventureJULY Make It!AUGUST Outdoor AdventureAUGUST Make It!