Program Application

Admin Email

Unique ID

ADMIN: Application Status

Program of Interest*

ADMIN: Session Approved to Attend

ADMIN: Facilitator

ADMIN: Year

Select Location*

How did you hear about this program?*

Other (Please indicate)

About You

First Name*

Middle Name

Last Name*

Preferred Name

Date of Birth*

Your Age Range*

Age at time of applying

Mailing Address

Street 1*

Apt/P.O Box

City*

Province*

Postal Code*

Contact Information

Phone 1*

Phone 2

Alternate Phone 2

Email*

Alternate Email

Previous Programs Taken

Have you taken previous SJWEN programs?*

Previous Program(s)

Employment Status

Are you currently employed?*

Are you currently receiving social assistance?*

Disclsoure

Please read

I agree to the information sharing policy.

Information Sharing Consent Form

The Saint John Women’s Empowerment Network (WEN) takes photographs/videos of and interviews individuals for the purposes of promotion/celebration in various media (e.g. media, printed materials, website, social media). We also collect information through presentations, programs, and projects.

CONSENT
I consent to the use and disclosure of my name and all images/videos and information of or including me by WEN, in whole or in part, for distribution to the general public for the purposes of publicity and promotion in various media (e.g. printed materials, website, social media, funding reports, media).

I further consent to the reproduction or use of the photographs/videos/information with or without my name. In giving this consent,

I release WEN from liability for any violation of any personal or proprietary right I have in connection with any sale, reproduction or use of the photographs/interviews.

I certify that I am 19 years of age or older. ⬜
By checking this box, I also consent to being tagged on social media. ⬜

I have read the above, understand it, and agree to this consent form.

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