This form is intended to capture key information that will be presented on Action Canada for Sexual Health and Rights' public, online directory of youth-friendly sexual health care providers, on our larger sexual health hub.
The Action Canada for Sexual Health and Rights hub will be available at www.actioncanadashr.org and used for the purpose of providing the general public with an accurate directory of available, youth-friendly sexual and reproductive health services available across the country.
After submitting this form, you will be directed to a short "Youth Friendly Sexual Health Care Provider" Checklist. Please check all criteria that applies to your clinic.
Please fill out the following information as you would like it to appear on the directory.
I understand that for increasing access to sexual and reproductive health, the information provided above will be made public on Action Canada for Sexual Health and Rights' online sexual health hub to increase youth's access to youth-friendly sexual and reproductive health services.
I understand that the above-mentioned clinic, hospital, or centre, as well as contact information, will appear on this online directory.
I understand that individual people's names and their addresses will not be made public on the directory.
I agree with the terms and conditions in this agreement, and hereby grant Action Canada for Sexual Health and Rights the right and permission to publish the information disclosed in this form regarding the services offered at said clinic, hospital, or centre. I further agree to hold harmless Action Canada for Sexual Health and Rights from and against any and all damages and claims.
Please provide your mailing address so we can send you a welcome package, including posters identifying your clinic as a youth-friendly point of service!
Submitting this form will act as my signature.