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YARD Referral Form

NOTE: Fields marked with * are mandatory.
Date of referral *
Select a date from the calendar.
Referred By *

Referral source phone number *
Referral source email *
Referral source/Organization *

Who is aware of the referral to YARD? *
Primary eligibility factors
Secondary eligibility factors
Additional eligibility factors
Additional information on eligibility
Youth name *

Youth address *

Youth phone number *
Youth cell phone number
Youth email address
Date of birth *
Select a date from the calendar.
Gender *

Population group *

Country of birth *

Year of arrival in Canada

Is English a second language for the youth?

Primary language spoken at home

Current school status *

Last attended school
If the youth is not attending school, when did they last attend?

Anticipated return to school date

School currently attending or last attended

Current grade or last grade attended

Any previous suspensions?
If yes, how many suspensions?

Years in which suspension(s) occured

Any previous explusions?
If yes, how many expulsions?

Years in which expulsion(s) occured

Health issues
Provide details about any suspected or diagnosed health issues, including any counseling or treatment received, and any medication taken.

Physical disability(ies)
Mental health issue(s)
Substance abuse
Conduct disorder
Learning disability
Youth lives with

If other, please provide the name

Child and Family Services status

If other, please provide Child and Family Services status

Does the youth have a criminal record, or has the youth been charged with a criminal offence?

If yes, please provide details
Name of probation officer
if applicable

Is the youth recieving help from any other program or service?

If yes, which program/service?

Does the youth want to participate in YARD?

If No or Don't Know, why not?
We would encourage you to engage the young person to make them aware of the YARD program
Parent/Guardian full name

Parent/Guardian address

Parent/guardian phone number
Parent/Guardian email address
Is English a second language for the parent/guardian?
What is the parent/guardian's primary language(s) spoken?

Does the youth's parent/guardian want the youth to participate in YARD?

This personal information is being collected under the authority of section 33(c) of the FOIP Act RSA 2000 and will be used by the City of Calgary and the Calgary Police Service to determine eligibility for YARD. The child’s personal information will also be used to administer and evaluate YARD and for contact purposes regarding other programs or services for which the child may be qualified. All information collected is protected by the provisions of the FOIP Act RSA 2000. You may direct questions about the collection, use or disclosure of your personal information by this program by calling the YARD Information Line at 403-428-8409.