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SECTION A: Contact Information
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First Name:
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Last Name:
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Organization:
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Position:
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Address:
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Phone:
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Fax:
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City:
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Province:
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Country:
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Postal Code:
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Email Address:
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What contact information would you like given to youth for referrals? (for example, direct phone line, front desk phone number, email address, organization's website address, etc.)
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Are you able to provide services in a language(s) other than English?
If so, please list all languages (including sign language):
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SECTION B: General
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Why do you want to be an Ally?
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How did you find out about the Ally program?
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What can you offer lesbian, gay, bisexual and transgender youth?
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Are you willing to be an Ally to: (check all that apply)
Youth (18 and under)
Youth (19-25)
Adults (26 and over)
Other - please define:
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You would best describe your role for youth as being a: (choose one)
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SECTION C: Service Providers
*to be filled out by Service Providers ONLY*
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What service(s) do you provide?
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What population(s) do you work with?
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Are there fees associated with your services?
Yes No
If so, please provide details below:
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| **Not Applicable** |
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SECTION D: Lesbian, Gay and Bisexual Youth
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What experience do you have working with lesbian, gay and bisexual youth and/or clients?
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Would you be interested in receiving further resources/information relevant to lesbian, gay and bisexual youth?
Yes No
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Would you be interested in receiving further information on training opportunities regarding lesbian, gay and bisexual youth?
Yes No
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Is there anything else you might need in order to be an effective Ally to lesbian, gay and bisexual youth?
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SECTION E: Transgender Youth
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What experience do you have working with transgender youth and/or clients?
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Would you be interested in receiving further resources/information relevant to transgender youth?
Yes No
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Would you be interested in receiving further information on training opportunities regarding transgender y outh?
Yes No
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Is there anything else you might need in order to be an effective Ally to transgender youth?
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SECTION F: Ally Networks
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Ally Networks exist in some organizations, workplaces and communities across Nova Scotia, and work to coordinate the promotion of the Ally program, provide training to Allies, and offer social events and networking opportunities for Allies.
If you have an affiliation with any of the following networks, please inidicate below. (By identifying an affiliation with a Network below, you agree to have your contact information shared with the existing Ally Network administrator at that organization.
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Are you interested in setting up an Ally Network in your community or place of work?
Yes No
If you answered Yes, what is the name of the community or place of work that you would like to create an Ally Network for?
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Create Password
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New Password:
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Confirm Password:
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