Black Youth Visionary Program Registration Form

Black Youth Visionary Program Registration Form

Thank you for your interest in joining the Black Youth Visionary Program (BYVP).

BYVP is designed to support and connect Black-identifying students to the resources, skills, and connections towards academic and personal success.

Please complete the registration form below to help us learn more about you and how we can best support you. Any information provided in this form, We’re excited to have you with us!

The Black Youth Visionary Program aims to be as inclusive and accessible as possible. If there is a specific accommodation you require, please do not hesitate to reach out to blackvisionary@ontariotechu.ca.

Privacy and Data Use Statement:
Personal information on this survey is collected under the authority of the University of Ontario Institute of Technology Act, SO 2002, c. 8, Sch. O. and will be collected, protected, used, disclosed and retained in compliance with Ontario’s Freedom of Information and Protection of Privacy Act R.S.O. 1990, c. F.31. This information will be used for program development, delivery, and evaluation. Questions regarding the collection of your personal information may be directed to: Ontario Tech University Access and Privacy Office, 2000 Simcoe Street North, Oshawa, ON L1H 7K4, 905.721.8668, ext. 6705, email: accessandprivacy@ontariotechu.ca.

Name Name First Last
Ontariotechu.net email
Student number
Maximum of 9 characters allowed. Currently Entered: 3 characters.
Personal pronouns

Personal pronouns He/Him She/Her They/Them Ze/Zire I prefer not to say Other

By asking for your pronouns, we aim to address and refer to you accurately and respectfully.
I am a:

I am a: Undergraduate student Graduate student
What is your faculty?
What is your program?
Are you required to do a co-op and/or internship as a part of your program?

Are you required to do a co-op and/or internship as a part of your program? Yes No I don't know
Current year of study
Expected graduation year
In order to best support the Black student community at Ontario Tech, please identify which of the following best applies to you. Select all that apply.

In order to best support the Black student community at Ontario Tech, please identify which of the following best applies to you. Select all that apply. Asian-Caribbean (e.g. Guyanese, Trinidadian) Black Black-African (e.g. Ghanaian, Kenyan, Nigerian, Somali) Black-Caribbean (e.g. Barbadian, Jamaican, Grenadian) Black-European (e.g. British, French, Spanish, Portuguese) Black-North American (e.g. Canadian, American) Black-South and Central American (e.g. Brazilian, Panamanian) Other Other

By agreeing to self-identify, our team will be able to confirm your eligibility to participate in the Black Youth Visionary Program.
Please indicate if you identify with any of the following populations. Check any or all that apply.

Please indicate if you identify with any of the following populations. Check any or all that apply. First generation student International student Indigenous student Mature student Transfer for Pathways student None of these apply to me
Are you currently a member of any official Ontario Tech athletics teams?

Are you currently a member of any official Ontario Tech athletics teams? Yes No
Do you hold any of the following student positions? Check any or all that apply.

Do you hold any of the following student positions? Check any or all that apply. Equity Advocate International Student Leader Orientation Leader Peer Educator Peer Employment Advisor Peer Mentor (Student Engagement & Equity) Peer Wellness Educator Ridgeback Student Voices Creator Student Enrichment Program Student Mental Health Peer Mentor Sustainability Champion University Works Student OTSU club or society executive OTSU club or society general member Women for STEM member None of these options apply to me
How did you hear about the Black Youth Visionary Program?

How did you hear about the Black Youth Visionary Program? Email Ontario Tech mobile Word of mouth Ridgeback Report newsletter Social media Posters and digital signage Other Other
By checking off this box, I understand that in order to join in the Black Youth Visionary Program, I am required to complete a virtual or in-person intake session with a Diversity, Inclusion, and Belonging staff member.

By checking off this box, I understand that in order to join in the Black Youth Visionary Program, I am required to complete a virtual or in-person intake session with a Diversity, Inclusion, and Belonging staff member. Yes