Name: LDANR’s 2022 Virtual Trivia Night Fundraiser!
Start: 2022-03-25T18:30:00-04:00
End: 2022-03-25T21:00:00-04:00

Step 1 of 9

Please note, the LDANR's primary form of communication is through email.
Primary Contact Name*
The Primary Contact is the person who will receive communication about the program from LDANR staff.
Title First Name Last Name
Primary Contact Email*
Primary Contact Phone Number*
Address*
Street Address City Postal Code
Municipality*
If you are unsure which Niagara municipality you are located in, please refer to the section below.
Please Specify:*
Municipality of Fort Erie: Cities include Crystal Beach, Fort Erie, Ridgeway, Stevensville

Municipality of Grimsby: Cities include Grimsby

Municipality of Lincoln: Cities include Beamsville, Campden, Jordan Station, Vineland, Vineland Station

Municipality of Niagara Falls: Cities include Niagara Falls

Municipality of Niagara on the Lake: Cities include Niagara on the Lake, Queenston, St. Davids, Virgil

Municipality of Pelham: Cities include Fenwick, Fonthill, Ridgeville

Municipality of Port Colborne: Cities include Port Colborne, Sherkston

Municipality of St Catharines: Cities include St Catharines

Municipality of Thorold: Cities include Allanburg, Port Robinson, Thorold

Municipality of Wainfleet: Cities include Wainfleet, Lowbanks

Municipality of Welland: Cities include Welland

Municipality of West Lincoln: Cities include Binbrook, Caistor Centre, Canfield, Grassie, Smithville, St. Anns, Wellandport
Secondary Contact Name
The Secondary Contact is the person who will be contacted if the Primary Contact cannot be reached.
Title First Name Last Name
Secondary Contact Email
Secondary Contact Phone Number
Member Status*
- Non-Member
- Current Member
Who does the applicant primarily reside with?*
Who has custody of the applicant?*

Applicant's Name*
This is the name of the individual who would be attending the program, if accepted.
First Last
Applicant's Gender
- Female
- Male
- Non-Binary
Birth Date (dd/mm/yyyy)*
DD slash MM slash YYYY
Age*
Grade*
School Board*
Please Specify:*
School

Does the applicant have any SEVERE allergies that require an Epipen?*
- Yes
- No
What allergy does the applicant carry an EpiPen for?*
Other Medical Concerns*

E.g. Epilepsy, Diabetes, Nosebleeds etc.
Doctor's Name
Doctor's Phone Number
Emergency Contact - Name*
In case the Primary Contact cannot be reached.
Emergency Contact - Phone*
Emergency Contact 2 - Name
Emergency Contact 2 - Phone

Does the applicant have a formal diagnosis of a learning disability? (i.e. reading disability (dyslexia), math disability (dyscalculia), writing disability(dysgraphia))*
Please visit the website for the definition of a learning disability.
- Yes
- No
- I don't know
Type of LD:
Who made the diagnosis?
When?
Note: To be accepted into the program the applicant does not have to be formally diagnosed or identified with a learning disability, but must show signs of having a suspected learning disability.
Is the applicant diagnosed with other exceptionalities?*
(i.e. AD(H)D, OCD, Autism, Auditory Processing Disorder, Intellectual Disability)
- Yes
- No
Please list all exceptionalities and dates of diagnosis.*

Applicant's special interests, abilities, hobbies, sports?*
i.e. baseball, swimming, art, video games
What embarasses the applicant most?
i.e. difficulties in group setting, being singled out
How does the applicant function in a group setting?*
(i.e. better one-to-one, is shy in a group etc.)
What would you like the staff and volunteers working with the applicant to know about them?*

Does the applicant display verbally aggressive behaviour?*
(i.e. swearing/insulting others/disrespectful language)
- Yes
- No
Please provide further detail:
Other than verbal aggression, if the applicant displays other forms of behaviour issues, please list them in the space provided:

Are you familiar with the Microsoft Teams platform?*
The LDANR uses Microsoft Teams as our online program platform. If accepted into the program, we will use this information to identify individuals who may require additional support accessing the platform.
- Yes
- No
- Somewhat
Please confirm that you would like the applicant to participate in this opportunity by carefully reading and agreeing to the statements of understanding below:
- I confirm that the applicant will have access to a working device (i.e. computer, tablet) with microphone, camera, and internet connectivity.

Youth to Youth Program Application

Step 1 of 9

Supporting Documents