Membership Application

SURVIVOR MEMBERSHIP APPLICATION

Document No.

SSISC-FRM-001

This form is strictly confidential. All information is collected, stored, and used in accordance with SSISC policies and applicable Canadian privacy legislation.

Section A

Applicant Information

Full Legal Name*

Preferred Name

Date of Birth*

Mailing Address*

City*

Province*

Postal Code*

Phone Number

Email Address*

Preferred Method of Contact

Phone

Mail

Section B

School Information

Section C

Verification Documents

Please attach one or more of the following documents to verify your attendance:

Upload verification documents

PDF, JPG, PNG — max 10 MB each

Section D

Optional Demographic Information

This section is entirely optional. Information provided helps SISCC better understand and serve its membership.

Section E

Survivor Experience Data (Optional)

This section is entirely optional. You are not required to disclose any details of your experience to become a member.

Section F

Consent

I consent to the collection, storage, and use of my information in accordance with SSISC policies.

I understand that anonymized information may be used for research, advocacy, reporting, public education, grant applications, and government submissions.

Signature (Full Name)*

Typing your name constitutes a legal electronic signature.

Date*

SSISC-FRM-001

SURVIVORS OF SASKATCHEWAN INDEPENDENT SCHOOLS COALITION (SSISC)

Both consent statements must be acknowledged before submitting.