AYA Support Network - HealthLink Specialist Philanthropy Society

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Past Global Initiatives
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Email:
healthlink.sp@gmail.com

Address:
20164 81A Ave Langley, BC

About Us
Services
Past Global Initiatives
Contact

AYA Support Network

We would love to have you in our support network.

Kindy fill the form below to register today.

Participant Registration Form

AYA Support Network – Participant Registration Form

Section 1: Personal Information

Full Name:

Preferred Name (if different):

Pronouns:

She/Her

They/Them

Other

Age Range:

Under 18

18–24

25–34

35–44

45+

Email Address:

Phone Number:

City / Community:

Section 2: About You

1. How did you hear about the AYA Support Network?

Social Media

HSPS Website

Friend/Peer

Health Provider

Community Partner

Other

2. What brings you to this support group?

3. What type of sessions would you prefer?

Virtual

In-person

Hybrid

No preference

4. When are you most available?

Weekdays (Evenings)

Weekends

Flexible

Section 3: Support Preferences

1. What kind of support are you looking for?

Peer connection and shared experiences

Health education and information sessions

Mind-body wellness (yoga, journaling, group discussions)

Mental-health or counselling referrals

Advocacy and resource navigation

Other

2. Do you have any accessibility needs, allergies, or sensitivities we should be aware of?

Section 4: Consent and Confidentiality

Participation Consent:

I understand that the AYA Support Network is a peer and community-based program designed to promote wellness, not a substitute for medical care. Participation is voluntary, and I may withdraw at any time.

Confidentiality:

I agree to respect the privacy of other participants and maintain confidentiality about what is shared during sessions.

Signature:

Date:

Section 5: Emergency Contact (Optional)

Name:

Relationship:

Phone:

Section 6: Wellness Check-In (Optional)

On a scale of 1–5, how are you feeling about your reproductive or emotional wellness today?

1️⃣ Very low

2️⃣ Low

3️⃣ Neutral

4️⃣ Good

5️⃣ Very good

Would you like to be added to our HSPS mailing list for upcoming workshops and peer sessions?

Yes

No

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