Name *

First Name

Last Name

Phone

(###)

###

####

What is your age? *

17 & Under

18-24

25-34

35-44

45-54

Over 55

Shipping Address *

Where should we ship your program materials? Open to Canadian Residents only.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Meditation (Wed Jan 11th @ 1:00pm ET) *

Yes - I would like to attend this session

No - I am not available/not interested

Making a Wellness Plan (Wed Jan 18th @ 1:00pm ET) *

Please add me to the waitlist

No - I am not available/not interested

Grounding (Wed Jan 25th) @ 1:00pm ET *

Yes - I would like to attend this session

No - I am not available/interested

How did you hear about this program? *

Social media

Newsletter

Website

Friend/Family Member

Flyer

Health Care Provider

Other

Would you like to stay in the loop about future program offerings? *

Yes

No

I understand that this program is offered virtually via the Keep Your Head Up Microsoft Teams platform *

I understand

I acknowledge that these programs are intended for individuals living with the effects of traumatic brain injury, including concussion. *

Yes

Code of Conduct *

The Keep Your Head Up Foundation (KYHU) is committed to providing a safe, productive, and welcoming environment for all participants, instructors and volunteers. All those who attend virtual programming are expected to abide by this Code of Conduct. KYHU reserves the right to remove participants from virtual programs if they are in violation of the Code of Conduct in order to create a safe and successful virtual program experience for all. KYHU has zero tolerance for any form of discrimination or harassment, abusive or foul language towards other participants, program staff and/or volunteers. Participants are expected to: i) Show respect to all participants, program staff and volunteers; - Treat participants, program staff, and volunteers the way you would want to be treated. - Be considerate and honour the feelings, and opinions of others ii) Exhibit appropriate behaviour for virtual programming; - 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 by the instructor. Using this signal will show that you are listening. iii) Help create a safe and confidential space; - Our virtual programs are safe spaces in which we encourage growth and personal reflection. We ask that you hold all conversations confidential to recognize the sensitivity of others’ comments. Please demonstrate respect for everyone's dignity, confidentiality and capacity to contribute. iv) Refrain from delivering critical feedback during programs; - We ask that you please provide feedback by email or through feedback surveys provided after sessions.

I Agree to abide by the Code of Conduct