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Resource Centre for Suicide Prevention
Resource Centre For Suicide Prevention
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Registration / Referral Form

Youth Information

(Please provide details to the best of your knowledge. Information provided is confidential.)

Youths Full Name(Required)
Does youth identify as First Nations, Metis, or Inuit?
MM slash DD slash YYYY
Has this youth attended one of our workshops in the past?
This is my
This is my

Emergency Contact Information

Emergency Contact Name
This is my
This is my

Registrant Information

I am filling out this registration form as the(Required)
Is the youth aware of this registration and in agreement to the program?(Required)
Is parent/guardian aware of registration and in agreement to the program?(Required)
Please make parents aware the registration has been made for their child.
Name of Parent / Foster Parent / Guardian(Required)
Your Name

Policy Acknowledgement

Programming Removal Policy(Required)
There may be situations where a youth is asked to leave programming and the parent/guardians are required to pick them up. These situations can include but are not limited to:
– Aggressive or abusive behavior towards staff or other participants including, but not limited to: name calling, harassment, vulgar or inappropriate behavior, physical altercations, etc.
– Refusing to participate in the workshops activities or cause disruptions in the programming for the rest of the individuals.
– Possession or use of cell phones and tablets during workshop hours.
– Unwillingness to follow the rules or group guidelines that leads to the disruption of the workshop.
– Any other situation where program staff feel it is in the best interest of the individual or group.
Confidentiality
The Resource Centre for Suicide Prevention and all of its programs (Including the Phoenix/Gryphon Group) maintains confidentiality of participant information.
– After participating in the program, our staff will inform the parent/guardian of any other agency or program which may be of benefit to the youth. If the participant was referred by a third party, that party may receive this follow-up information.
– Program staff may recognize opportunities for referral to outside

(Please provide details to the best of your knowledge. Information provided is confidential.)

To promote mental well-being, raise awareness, eliminate stigma, and educate to reduce suicide, suicidal behaviours and their impacts.

Grande Prairie Office

780-539-6680 info@sp-rc.ca

Grimshaw Office

780-219-6442 northpeace@sp-rc.ca

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