Name *

First Name

Last Name

Phone

(###)

###

####

Age *

18-19

20-22

23-25

I live in the Waterloo Region. *

Cambridge, Kitchener and Waterloo, and the townships of North Dumfries, Wellesley, Wilmot and Woolwich.

Yes

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Have you participated in a focus group before? *

Yes

No

I acknowledge that this focus group is intended for individuals 18-25 living with the effects of traumatic brain injury, including concussion. *

Yes

I understand that compensation is reserved for those who attend and participate in the focus group discussion *

I understand

By checking the boxes below, I agree to the following: *

I confirm that participation in this focus group is voluntary

I acknowledge that I have the right to decline or discontinue my participation in the focus group if/when I do not wish to

I have read and understand the purpose of this focus group and how it will affect the target audience

I acknowledge that this focus group is intended for individuals 18-25 living with the effects of traumatic brain injury, including concussion

I confirm that I will respect the privacy and confidentiality of other participants by keeping all identities and comments shared by other participants in the focus group confidential.

I understand that my information and contributions will be kept confidential by the organization

I understand that the experiences, ideas and information I provide may be used to help design programs and resources

Code of Conduct *

The Keep Your Head Up Foundation (KYHU) is committed to providing a safe and welcoming environment for all participants. All those who attend the focus group are expected to abide by this Code of Conduct. KYHU reserves the right to remove participants from the focus group if they are in violation of the Code of Conduct in order to create a safe and successful experience for all. KYHU has zero tolerance for any form of discrimination or harassment, abusive or foul language towards other participants, staff and/or volunteers. Participants are expected to: i) Show respect to all participants, staff and volunteers; - Treat participants, staff, and volunteers the way you would want to be treated. - Be considerate and honour the feelings, and opinions of others, even if they are different from your own. ii) Exhibit appropriate behaviour for virtual meetings; - Be mindful of how statements, language, jokes, and tone can all be interpreted differently online; avoid sarcasm. - Listen while others are speaking - Raise your hand prior to speaking, unless otherwise specified. iii) Help create a safe and confidential space; - Please demonstrate respect for everyone's dignity, right to privacy and their individual capacity to contribute.

I Agree to abide by the Code of Conduct