Indian Residential School Survivors Society
Suite 911 - 100 Park Royal South
West Vancouver, BC
V7T 1A2		    
     
Registration Number:___________    
Full Name:____________________   Nation:__________________________
Address:________________________    

Other:__________________________

    
Band:___________________________   PHONE:__________________________
Birthdate:_______________________   Email:___________________________

TYPE OF MEMBERSHIP

  
Annual Membership Dues $1.00
Survivor
   
Family of Survivor
 
Signature: ___________________
Associate Member*
 
DATE: ___________________
Honorary Member*
 

 

*Associate and Honorary Members can attend and speak at
meetings but may not vote or hold positions at the Society.

Member Start Date:_________________ Member End Date:________________

Information given will be kept strictly confidential.

Attached is an optional survey. You will not be identified on this survey. The purpose is to assess how many survivors are in BC, where they live, and what their needs are.

 

 


IRSSS Residential School Survey

About the Survivor  
Where do you live? _____________________________ Age ______
   
Residential School Information  
Residential School Attended ______________________ Years Attended ______
   
While Attending Residential School, did you experience: 
Physical Abuse Spiritual Abuse  
Sexual Abuse Emotional Abuse  
   
Are you interested in seeking justice for the abuse at residential school? 
Yes If yes, what type of justice? Circle: Criminal/Civil/ADR/Class Action
No Comments:______________________________________________
If you want more information, please call our office.  
   
Cultural (Traditional way of Life)  
Before Residential School did you: After Residential School did you:
Speak your language? Speak your language?
Participate in ceremonies? Participate in ceremonies?
Know how to gather and preserve food? Know how to gather and preserve food?
Do other traditional things? Do other traditional things?
  Did you return home?
   
Healing  
What would assist you with your healing?  
Therapist Traditional Healer Other:
Counsellor Healing Circle
   
Health  
Are you experiencing health problems because of your Residential School experience?
Yes If yes, please describe________________________
No ___________________________________________
   
Education  
What grade did you complete at Residential School? Grade:_____________
After Residential School did you attend:  
University College Trade School Other:______________________________________________
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