2012 Ontario DCL Conference
June 3 to 5, 2016
Chelsea Hotel, Toronto
Registration Form
(Delegates and Observers)
SECTION #1 - PERSONAL INFORMATION
NAME
DIRECTLY CHARTERED LOCAL OR COMPONENT
LOCAL #
PSAC ID #
HOME ADDRESS
CITY, PROVINCE
POSTAL CODE
HOME TELEPHONE #
WORK TELEPHONE #
CELLTELEPHONE #
PERSONAL EMAIL
UNION EMAIL
AEROPLAN #
EMERGENCY CONTACT / CONTACT #
SECTION #2–DELEGATE/OBSERVER STATUS
I am applying to the 2016 PSAC Ontario Regional Women’s Conference as a:
Delegate / Observer
From:
My Local / My Regional Women’s Committee / Other / Please Specify:
______
NOTE: Observer Status
If you are not selected as a Delegate to the Conference, do you want to be considered as an Observer?
Yes / NoPlease Note: Observers are responsible for securing their own travel and for covering all costs associated with their participation in the Conference. Observers will also be responsible to arrange for any childcare or accommodation needs directly with the hotel.
NOTE: Conference Venue
The PSAC has reserved a block of rooms at the Chelsea Hotel, Toronto. The hotel is unionized and accessible.
NOTE: Additional Information:
- The Chelsea Hotel has a pool, so you may wish to bring a swimsuit.
- We will set up a box for collection of hotel soaps and shampoo, etc. for women’s shelters. This box will be located in the Administration room.
- In-room internet service at the Chelsea Hotel is complimentary.
SECTION #3–Equity Group Self-Identification (Optional)
PSAC members who belong to the following groups are invited to Self-Identify. This information is voluntary and kept confidential and will be used for the purposes of supporting our equity initiatives and programs. Please check all that apply. Identifying as a woman is required for participation at the Conference.
Woman / Member With a Disability
Aboriginal Member / Gay, Lesbian, Bi-Sexual or Transgendered Member
Racially Visible Member / Young Worker (age 35 or under)
SECTION #4 - ROOM ACCOMMODATION
Accommodations are based on single occupancy with an option to share rooms. Please indicate if you are willing to share a room and the name of the person with whom you are willing to share in the space below.
SECTION #5 - TRAVEL ARRANGEMENTS
Please indicate your mode of travel.
Participants are expected to travel by the most direct, economical means.
Air
Rail
Bus
Personal Motor Vehicle
Will you be carpooling? Please indicate with whom.
SECTION #6 - DIETARY REQUIREMENTS
In the space below, please indicate if you have any special dietary requirements or accommodation needs. Please be as specific as possible to assist the Organizing Committee and the facility in meeting your needs.
NOTE: This is a NUT FREE Conference.
Special Diet: / Other (Please Specify):
Vegetarian / Vegan / Gluten Free
Allergies (Please Specify):
Special Needs (Please specify):
SECTION #7–ACCOMMODATION FOR MEMBERS WITH DISABILITIES
The PSAC Accommodation Policy for Delegates at PSAC Conferences strives to ensure that conferences are barrier-free for Delegates with different abilities. Once selected, members may be required to further specify their accommodation requests in order to facilitate their participation in the Conference.
Please be as specific as possible to assist the Organizing Committee and the facility in meeting your needs.
I will be accompanied by a personal care attendant to assist me at the conference.
Comments: ______
I require documentation in alternative media.
Comments: ______
I require sound amplification.
I require a sign language interpreter.
I require an oral interpreter.
I require that the PSAC arrange for a Reader (for a person with visually related-disability) to assist me in order to fully participant at the Conference.
I will be using animal assistance (ie: guide dog) at the Conference.
I will require other accommodation:
Comments: ______
______
What are the functional limitation arising from your disability? (You are not obliged to disclose your diagnosis, only your functional limitations.)
Comments: ______
______
Please Note: You may be required to provide relevant medical documentation that will assist us to respond to your request. This information will not be disclosed except where necessary to respond to your request for accommodation.
Allergies (Please Specify):
Other Special Needs (Please specify):
SECTION #8 - ENVIRONMENT
SMOKE FREE: All PSAC events, including this course, are smoke free. All rooms are non-smoking. There are designated smoking areas outside the facility.
SCENT FREE: To assist members with environmental sensitivities, all PSAC activities will be scent-free events.
NUT FREE: Delegates need to be aware that a very serious nut allergy has been identified. Please ensure that no nuts are brought to the Plenary or break-out rooms or anywhere in the common areas adjacent the Conference space.
STATEMENT ON HARASSMENT: All PSAC events are harassment free. We can neither condone nor tolerate behaviour which undermines the full and equal participation of all in union activities.
- SPECIAL NEEDS - ACCESS AND DIET REQUIREMENTS: The PSAC is committed to ensuring that the accessibility and dietary requirements of our members are respected. Please indicate your needs in Section #7 above and provide any necessary explanation that will assist us in meeting them. PSAC will take the necessary action to ensure the availability of transportation, equipment and/or people required to enable all members to attend and fully participate in this Conference.
SECTION #9 - FAMILY CARE
The PSAC Family Care Policy is intended to assist members in covering additional fees incurred as a direct result of attending an authorized PSAC activity. The objective of the Policy is to remove one of the barriers which prevent members from fully participating in union activities.
If there are any Delegate requests, on-site child care will be provided at the Conference. Please indicate below:
I require on-site child care.
Number of Children: ______
Children’s Names and Ages: 1. ______
2. ______
3. ______
4. ______
SECTION #10 - PARTICIPANT PROFILE
To ensure that the Conference meets the needs of our Delegates, we strongly encourage you to respond to each of the following questions and/or check all that apply.
This is my first PSAC Regional Women’s Conference.
I have recently attended other PSAC/Component/Directly Chartered Locals Conferences, Conventions or functions.
Please Specify: ______
______
______
In the past 2 years, I have attended a PSAC, Component or Joint Learning Program (JLP) education course.
Please Specify: ______
______
______
I am a member of a PSAC Regional or Component Human Rights or Equity Committee.
Please Specify: ______
______
______
I am active in the community for whom this Conference is intended (ie: Regional Women’s Committee, Equity Committee, District Labour Council, etc.).
Please Specify: ______
______
______
I am active in the workplace on women’s and/or equity issues.
Please Specify: ______
______
______
I am an Alliance Facilitator and/or Joint Learning Program Facilitator and, if I am confirmed as a Delegate, I would like to be considered to facilitate one of the workshops.
If you are an Alliance Facilitator or a Joint Learning Program Facilitator, what courses have you facilitated?
Please Specify: ______
______
______
I am NOT an Alliance Facilitator and/or Joint Learning Program Facilitator but I AM interested in the opportunity to facilitate at the 2016 Ontario Regional Women’s Conference.
Briefly explain why you would like to facilitate: ______
______
______
SECTION #11 - PSAC CONTACT LIST CONSENT
I hereby consent to have my name and email address(es) added to the one or more of the PSAC contact lists.
Please note that that this information may be shared with different structures only within the Union.
Please remit this completed Registration Form to the PSAC Kingston Regional Office by:
MARCH 4, 2016
Attention: Kellie Loshak
c/o PSAC Kingston Regional Office
By Mail: 412-1471 John Counter Blvd,
Kingston, ON K7M 8S8
By Fax: 613-542-7387
By Email:
APPLICANT SIGNATURE
SIGNATURE OF APPLICANT: / DATE:
CHAIR, RWC OR LOCAL PRESIDENT SIGNATURE
I approve the selection of the Delegate / Observer (please circle appropriate response) as a
Representative of Component / DCL ______(name) Local #______.
SIGNATURE OF CHAIR, RWC OR LOCAL PRESIDENT: / DATE:
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