JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Queen's Jack.org Summit 2021 Registration
Everyone on the Jack.org team is super excited for our school summit and we hope you are too. We would really appreciate a little more information on you!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name:
Your answer
Please provide demographic info: (gender, pronoun, sexual orientation, ethnicity, disability, lived experience with mental illness? yes or no) Note: this is just to get a better idea of who will be attending
Your answer
How did you hear about this summit?
Facebook
Instagram
word of mouth
Other:
Clear selection
What do you see as the main barrier(s) to optimum mental health in your community?
Your answer
What do you hope to take away from this summit?
Your answer
Please indicate how strongly you agree or disagree with each of the following statements from 1 (strongly disagree) to 5 (strongly agree)
I feel knowledgeable about mental health.
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
I can recognize the signs and symptoms of mental health struggles in myself and my peers.
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
I know exactly where to go for mental health support in my community, if needed.
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
If I were experiencing a mental health struggle, I would feel comfortable reaching out to my friends for help.
strongly disagree
1
2
3
4
5
strongly agree
Clear selection
Do you consent to photos taken being posted on our social media pages?
Yes
No
Clear selection
Do you consent to videos being taken and posted on social media?
Yes
No
Clear selection
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
