Surname:
(As On Health Card) / Given Name:
(As On Health Card)
Date of Birth: / Gender: / ___M ___F / Language Spoken: / __ ENG __ UKR __FRA ______Other
Name of Current School/Employer: / Program/Major: / Year:
Street & Apt#: / City:
Province: / Postal Code:
Home Phone # / Cell #:
E-Mail:
Member of the Ukrainian National Federation? / YES _____ NO______ / If Yes, Indicate which (city) Branch:
Parent(s) or Guardian(s) Information (If Participant is under 18 years of age)
Father’s (Or Guardian’s) Name: / Mother’s (Or Guardian’s) Name:
Name of Emergency Contact: / Emergency Contact Phone #:
Parent/Guardian Member of the Ukrainian National Federation? / _____ YES _____ NO / If Yes, Indicate which (city) Branch:
Pre-Existing Medical Conditions:
List any medical conditions that your child has and any medication to be administered:
Asthma: / Epilepsy:
Diabetes: / Other:
Allergies:
Excursion Registration: (Please Check All Weeks That Apply)
UNF Member Registration Rate $950.00 (Excluding Cost Of Travel)
Non-UNF Member Registration Rate $1,000.00 (Excluding Cost of Travel)
Signature and Acknowledgement:
I acknowledge that I have read and understand the Code of Conduct (On reverse of this form),payment options and refund limitations as follows: Because of a high enrollment and limited availability of space there is no refund of fees for cancellation from the excursion.
I agree to participate in all activities and abide by the code of conduct. I agree to pay the full registration as applicable above. I understand that any out of province or other applicable medical insurance is the responsibility of the registrant. If registrant is under 18 years of age, parent or guardian consents to this declaration and gives permission for the registrant to participate in the excursion on the terms and conditions set out on this form and accompanying brochure, and gives consent for organizers to seek such medical treatment for the registrant as they deem appropriate, in the event of emergency. Save for emergency and health related information, I(we) agree that the information collected in this application may be used by the UNF and its affiliated organization to facilitate or promote organizational goals, events or activities. Photographs and video of me/my child taken during the excursion may be published or used for not-for-profit purposes by the UNF of Canada or its affiliated organizations
Signed: ______Date:______
Code of Conduct
Participants (or Parent/Guardian) agree to abide by the code of conduct upon signing the registration form on the reverse side of this document.
1)Participants will at all times behave in a professional, respectful and courteous manner towards other participants, facilitators and others associated with the educational excursion. Use of profane or other offensive language is not permitted.
2)Participants will respect the property of and comply with the rules of the hosting organizations, facilities and residences.
3)Participants agree to be supportive of one another, assist each other in meeting the educational objectives of the excursion and to participate in excursion activities actively and to the best of their abilities.
4)As a wide range of participants is anticipated to take part, participants willbe mindful and inclusive and engage in activities appropriate for all participants
5)Participants will be courteous to their roommates. Room assignments provided by the organizers may only be changed with approval of the organizers.
6)Cell phones and other personal electronic devices are to be kept off during the excursion activities and presentations and should be used sparingly at all times.
7)Participants should use their judgment to get adequate rest to be able to take advantage of the activities.
8)The excursion is an alcohol, tobacco and drug free event, and all participants agree to refrain from their use.
9)Dress is mostly casual and should be appropriate to the nature of the event. Business attire should be packed by participants for one or two formal events.
10)Participants agree not to leave the excursion without advance written agreement of the organizers.
11)Failure to abide by this code of conduct may result in withdrawal from the excursion without refund of all fees.
Application Form Selection Criteria
As this Educational forum will strive to connect Students with their elected Members of Parliament in Ottawa, please identify your Member of Parliament, including name of constituency and political party:
Please identify one multicultural issue which is of interest to you or the Ukrainian Canadian community in your area :
Please drafta letter to your Constituency Member of Parliament requesting a meeting on the morning of Thursday September 26, 2013 and attach your draft letter to this application form.
Please explain why you wish to attend this educational forum:
Should a scholarship be available, would you be prepared toPledge to Commit to 100 hours of volunteer time within the Ukrainian Canadiancommunity? If yes, please identify which organization(s) or activities would you be interested in assisting and a contact name at one Ukrainian Canadian organization:
To reserve your place, please complete and FAX this form ASAP to 416-960-1442.
MAIL IN THE ORIGINAL WITH YOUR FULL $950.00 / $1000.00 REGISTRATION FEE (or a $200.00 Deposit) by August 30, 2013.
Mail to: UNF National Executive, 210-145 Evans Avenue, Toronto, Ontario,M8Z 5X8
Note: THIS EDUCATIONAL FORUM IS LIMITED TO 12 SELECTED CANDIDATES and is supported through a grant from the Shevchenko Foundation.
Revision 3
2013