<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>GMWS 2026 Registration Form</title>
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/* ── HEADER ── */
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/* ── REFLECTION QUESTIONS ── */
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</style>
</head>
<body>
<div class="page-wrap">
<!-- HEADER -->
<div class="header">
<p class="orgs">New African Canadians (NAC) & House of Wellness (HOW)</p>
<p class="header-present">Present</p>
<div class="conf-edition">
<span class="the-label">THE</span>
<span class="conf-number">4<sup>TH</sup></span>
</div>
<p class="conf-title">Global Mental Well-Being &</p>
<p class="conf-subtitle">Substance Misuse Conference</p>
<div class="badge-row">
<span class="badge">GMWS 2026</span>
<span class="badge badge-neutral">📅 July 30 – August 2, 2026</span>
<span class="badge badge-neutral">📍 UPEI, Charlottetown, PEI, Canada</span>
</div>
<div class="theme-block">
<p class="theme-label">Conference Theme</p>
<p class="theme-title">· Families · Communities · Futures</p>
<p class="theme-tagline">When families heal, communities thrive and economies grow</p>
</div>
</div>
<!-- FORM BODY -->
<div class="form-body">
<!-- 1. PARTICIPANT INFORMATION -->
<div class="section">
<div class="section-header">
<div class="section-icon">
<svg viewBox="0 0 24 24"><circle cx="12" cy="8" r="4"/><path d="M4 20c0-4 3.6-7 8-7s8 3 8 7"/></svg>
</div>
<span class="section-title">Participant Information</span>
</div>
<div class="field-row">
<div class="field">
<label for="fname">First Name <span style="color:#e24b4a">*</span></label>
<input type="text" id="fname" name="first_name" placeholder="e.g. Amara" autocomplete="given-name">
</div>
<div class="field">
<label for="lname">Last Name <span style="color:#e24b4a">*</span></label>
<input type="text" id="lname" name="last_name" placeholder="e.g. Okonkwo" autocomplete="family-name">
</div>
</div>
<div class="field-row">
<div class="field">
<label for="pronouns">Pronouns</label>
<p class="field-hint">e.g. She/Her, He/Him, They/Them</p>
<input type="text" id="pronouns" name="pronouns" placeholder="Your pronouns">
</div>
<div class="field">
<label for="email">Email Address <span style="color:#e24b4a">*</span></label>
<input type="email" id="email" name="email" placeholder="you@example.com" autocomplete="email">
</div>
</div>
<div class="field-row">
<div class="field">
<label for="phone">Phone Number</label>
<input type="tel" id="phone" name="phone" placeholder="+1 (_) _-__" autocomplete="tel">
</div>
<div class="field">
<label for="org">Organization / Affiliation</label>
<input type="text" id="org" name="organization" placeholder="Institution or organization name">
</div>
</div>
<div class="field-row">
<div class="field">
<label for="role">Role / Position</label>
<input type="text" id="role" name="role" placeholder="e.g. Social Worker, Researcher, Student">
</div>
<div class="field">
<label for="location">City / Province / Territory or State</label>
<input type="text" id="location" name="location" placeholder="e.g. Halifax, NS">
</div>
</div>
</div>
<hr class="divider">
<!-- 2. ACCESSIBILITY & INCLUSION -->
<div class="section" style="padding-top:0">
<div class="section-header">
<div class="section-icon">
<svg viewBox="0 0 24 24"><path d="M12 22s8-4 8-10V5l-8-3-8 3v7c0 6 8 10 8 10z"/></svg>
</div>
<span class="section-title">Accessibility & Inclusion</span>
</div>
<div class="field">
<label>Do you have any dietary or accessibility needs?</label>
<div class="yesno">
<label class="yn-label"><input type="radio" name="access_needs" value="no"> No</label>
<label class="yn-label"><input type="radio" name="access_needs" value="yes"> Yes — please specify below</label>
</div>
</div>
<div class="field">
<label for="access_detail">If yes, please describe your needs</label>
<textarea id="access_detail" name="access_detail" placeholder="Please describe any dietary restrictions, mobility, hearing, vision, or other accessibility requirements so we can best accommodate you…"></textarea>
</div>
</div>
<hr class="divider">
<!-- 3. CONFERENCE REFLECTION QUESTIONS -->
<div class="section" style="padding-top:0">
<div class="section-header">
<div class="section-icon">
<svg viewBox="0 0 24 24"><path d="M9 11l3 3L22 4"/><path d="M21 12v7a2 2 0 01-2 2H5a2 2 0 01-2-2V5a2 2 0 012-2h11"/></svg>
</div>
<span class="section-title">Conference Reflection Questions</span>
</div>
<p style="font-size:13px; color:var(--text-muted); margin-bottom:18px; font-style:italic;">In your view, what are the top two challenges in mental health and substance use today, and how might climate change be making them worse?</p>
<div class="reflection-item">
<p class="reflection-num">Challenge #1</p>
<p class="reflection-q">Describe the first challenge and the potential climate change connection.</p>
<textarea name="reflection_1" placeholder="e.g. Increased anxiety and trauma from extreme weather events, displacement, and climate grief — particularly affecting youth and marginalized communities…"></textarea>
</div>
<div class="reflection-item">
<p class="reflection-num">Challenge #2</p>
<p class="reflection-q">Describe the second challenge and the potential climate change connection.</p>
<textarea name="reflection_2" placeholder="e.g. Rising substance misuse as communities lose traditional livelihoods and cultural practices tied to the land due to environmental degradation…"></textarea>
</div>
</div>
<hr class="divider">
<!-- 4. OUTREACH & ENGAGEMENT -->
<div class="section" style="padding-top:0">
<div class="section-header">
<div class="section-icon">
<svg viewBox="0 0 24 24"><path d="M18 8h1a4 4 0 010 8h-1"/><path d="M2 8h16v9a4 4 0 01-4 4H6a4 4 0 01-4-4V8z"/><line x1="6" y1="1" x2="6" y2="4"/><line x1="10" y1="1" x2="10" y2="4"/><line x1="14" y1="1" x2="14" y2="4"/></svg>
</div>
<span class="section-title">Outreach & Engagement</span>
</div>
<div class="field">
<label>How did you hear about GMWS 2026? <span style="text-transform:none;font-weight:400;color:var(--text-muted)">(Select all that apply)</span></label>
<div class="check-group" style="margin-top:6px">
<label class="check-item"><input type="checkbox" name="source" value="social_media"> Social Media</label>
<label class="check-item"><input type="checkbox" name="source" value="friend"> Friend / Colleague</label>
<label class="check-item"><input type="checkbox" name="source" value="workplace"> Organization / Workplace</label>
<label class="check-item"><input type="checkbox" name="source" value="school"> School / University</label>
<label class="check-item"><input type="checkbox" name="source" value="community"> Community Group</label>
<label class="check-item"><input type="checkbox" name="source" value="website"> Website</label>
<label class="check-item"><input type="checkbox" name="source" value="email"> Email Invitation</label>
<label class="check-item"><input type="checkbox" name="source" value="previous"> Previous Conference Attendee</label>
<div class="other-inline">
<input type="checkbox" name="source" value="other_source" id="src_other_cb">
<label for="src_other_cb" style="font-size:13.5px;text-transform:none;letter-spacing:0;font-weight:400;color:var(--text-mid);">Other:</label>
<input type="text" name="source_other" placeholder="Please specify">
</div>
</div>
</div>
</div>
<hr class="divider">
<!-- 5. DEMOGRAPHIC INFORMATION -->
<div class="section" style="padding-top:0">
<div class="section-header">
<div class="section-icon">
<svg viewBox="0 0 24 24"><rect x="3" y="3" width="7" height="7" rx="1"/><rect x="14" y="3" width="7" height="7" rx="1"/><rect x="3" y="14" width="7" height="7" rx="1"/><rect x="14" y="14" width="7" height="7" rx="1"/></svg>
</div>
<span class="section-title">Demographic Information</span>
</div>
<p style="font-size:12.5px;color:var(--text-muted);margin-bottom:20px;line-height:1.6;">This information helps us understand who is participating in GMWS 2026 and ensure we are inclusive and representative. All responses are voluntary and confidential.</p>
<!-- Age Group -->
<div class="field">
<label>Age Group</label>
<div class="check-group">
<label class="check-item"><input type="radio" name="age" value="under18"> Under 18</label>
<label class="check-item"><input type="radio" name="age" value="18-24"> 18–24</label>
<label class="check-item"><input type="radio" name="age" value="25-34"> 25–34</label>
<label class="check-item"><input type="radio" name="age" value="35-44"> 35–44</label>
<label class="check-item"><input type="radio" name="age" value="45-54"> 45–54</label>
<label class="check-item"><input type="radio" name="age" value="55-64"> 55–64</label>
<label class="check-item"><input type="radio" name="age" value="65+"> 65+</label>
<label class="check-item"><input type="radio" name="age" value="prefer_not"> Prefer not to say</label>
</div>
</div>
<!-- Gender Identity -->
<div class="field">
<label>Gender Identity</label>
<div class="check-group">
<label class="check-item"><input type="checkbox" name="gender" value="woman"> Woman</label>
<label class="check-item"><input type="checkbox" name="gender" value="man"> Man</label>
<label class="check-item"><input type="checkbox" name="gender" value="nonbinary"> Non-Binary</label>
<label class="check-item"><input type="checkbox" name="gender" value="transgender"> Transgender</label>
<label class="check-item"><input type="checkbox" name="gender" value="two_spirit"> Two-Spirit</label>
<label class="check-item"><input type="checkbox" name="gender" value="prefer_not_gender"> Prefer not to say</label>
<div class="other-inline">
<input type="checkbox" name="gender" value="self_describe" id="gender_other_cb">
<label for="gender_other_cb" style="font-size:13.5px;text-transform:none;letter-spacing:0;font-weight:400;color:var(--text-mid);white-space:nowrap;">Prefer to self-describe:</label>
<input type="text" name="gender_other" placeholder="Please specify">
</div>
</div>
</div>
<!-- Racial / Ethnic Identity -->
<div class="field">
<label>Racial / Ethnic Identity <span style="text-transform:none;font-weight:400;color:var(--text-muted)">(Select all that apply)</span></label>
<div class="check-group">
<label class="check-item"><input type="checkbox" name="ethnicity" value="african_black"> African / Black</label>
<label class="check-item"><input type="checkbox" name="ethnicity" value="indigenous"> Indigenous</label>
<label class="check-item"><input type="checkbox" name="ethnicity" value="asian"> Asian</label>
<label class="check-item"><input type="checkbox" name="ethnicity" value="south_asian"> South Asian</label>
<label class="check-item"><input type="checkbox" name="ethnicity" value="middle_eastern"> Middle Eastern / Arab</label>
<label class="check-item"><input type="checkbox" name="ethnicity" value="latin"> Latin American / Hispanic</label>
<label class="check-item"><input type="checkbox" name="ethnicity" value="white"> White / European</label>
<label class="check-item"><input type="checkbox" name="ethnicity" value="mixed"> Mixed / Multi-racial</label>
<label class="check-item"><input type="checkbox" name="ethnicity" value="prefer_not_eth"> Prefer not to say</label>
<div class="other-inline">
<input type="checkbox" name="ethnicity" value="other_eth" id="eth_other_cb">
<label for="eth_other_cb" style="font-size:13.5px;text-transform:none;letter-spacing:0;font-weight:400;color:var(--text-mid);">Other:</label>
<input type="text" name="ethnicity_other" placeholder="Please specify">
</div>
</div>
</div>
</div>
<hr class="divider">
<!-- 6. CONSENT & AGREEMENT -->
<div class="section" style="padding-top:0">
<div class="section-header">
<div class="section-icon">
<svg viewBox="0 0 24 24"><path d="M9 11l3 3L22 4"/><path d="M21 12v7a2 2 0 01-2 2H5a2 2 0 01-2-2V5a2 2 0 012-2h11"/></svg>
</div>
<span class="section-title">Consent & Agreement</span>
</div>
<div class="consent-box">
<div class="consent-check">
<input type="checkbox" id="consent_agree" name="consent" value="agreed">
<label for="consent_agree" style="font-size:13.5px;text-transform:none;letter-spacing:0;font-weight:400;color:var(--text-mid);cursor:pointer;line-height:1.7;">
I agree to attend GMWS 2026 and uphold a respectful, inclusive space for all participants. I understand that photos and videos may be taken during the conference for reporting, outreach, social media platforms, and the conference website. All personal data collected will remain confidential and handled in accordance with applicable privacy policies.
</label>
</div>
</div>
<div class="sig-row">
<div class="field" style="margin-bottom:0">
<label for="signature">Participant Signature</label>
<input type="text" id="signature" name="signature" placeholder="Type full name as signature">
</div>
<div class="field" style="margin-bottom:0">
<label for="sig_date">Date</label>
<input type="text" id="sig_date" name="sig_date" placeholder="YYYY-MM-DD">
</div>
</div>
</div>
<!-- SUBMIT -->
<div class="submit-wrap">
<button type="button" class="btn-submit">Submit Registration →</button>
</div>
<!-- CONTACT FOOTER -->
<div class="contact-footer">
<div class="contact-tagline">
<strong>Together, let us build healthier families, stronger communities, and brighter futures.</strong>
Questions? Reach out to the GMWS 2026 organizing team.
</div>
<div class="contact-links">
<a href="https://www.globalmws.org" class="contact-link" target="_blank">
<svg viewBox="0 0 24 24"><circle cx="12" cy="12" r="10"/><line x1="2" y1="12" x2="22" y2="12"/><path d="M12 2a15.3 15.3 0 014 10 15.3 15.3 0 01-4 10 15.3 15.3 0 01-4-10 15.3 15.3 0 014-10z"/></svg>
www.globalmws.org
</a>
<a href="mailto:globalmentalwellbeing@gmail.com" class="contact-link">
<svg viewBox="0 0 24 24"><path d="M4 4h16c1.1 0 2 .9 2 2v12c0 1.1-.9 2-2 2H4c-1.1 0-2-.9-2-2V6c0-1.1.9-2 2-2z"/><polyline points="22,6 12,13 2,6"/></svg>
globalmentalwellbeing@gmail.com
</a>
<a href="mailto:newafricancanadians@gmail.com" class="contact-link">
<svg viewBox="0 0 24 24"><path d="M4 4h16c1.1 0 2 .9 2 2v12c0 1.1-.9 2-2 2H4c-1.1 0-2-.9-2-2V6c0-1.1.9-2 2-2z"/><polyline points="22,6 12,13 2,6"/></svg>
newafricancanadians@gmail.com
</a>
</div>
</div>
</div><!-- /form-body -->
</div><!-- /page-wrap -->
<script>
document.getElementById('sig_date').addEventListener('focus', function() {
if (!this.value) {
const today = new Date();
this.value = today.toISOString().split('T')[0];
}
});
</script>
</body>
</html>
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