Formulaire

KATIMAVIK
Application Form

*This form is part of the application
process and will be used when selecting participants
General Information
What community are you from? *

CreeTlicho
Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Gender*

FemaleMaleOther
What is your date of birth?*

MonthDayYear
Do you have any allergies or dietary restrictions?*

YesNo
If yes, Please specify which ones
Medical Information
What insurance coverage do you have?*

Provincial Health InsurancePrivate insurance
Health card insurance number*
Date of expiry*

YearMonthDay
Social insurance number
This information is not compulsory
Do you have any health problem that could affect your participation in the program? Please list them all*
Emergency Contact
Full Name*

PrefixFirst NameLast Name
Relationship*

Mother / FatherGrand parentAunt / UncleSister / BrotherFriendOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Phone Number 2

Area CodePhone Number
E-mail*
Education and Work experience

This section is used only for statistical purposes. Answers to the following questions will not affect your application.
Last Grade Completed*
Date of Diploma, certificate or degree (if applicable)

YearMonthDay
Courses Completed (if applicable)
Current Employer / Organization Name
Type of Work

EmployeeVolunteerIntershipCurrently unemployedOther
The erea of the employment
Duties or Responsibilities
Background information

This section is used only for statistical purposes. Answers to the following questions will not affect your application.
Marital Status

SingleMarriedIn a domestic partnershipDivorcedOther
Do you have any children?

YesNo
Average family income
Do you allow Katimavik and its partners to use photos or videos taken of you during the program?

YesNoOther
Motivation
What is your motivation to participate in this program?*

What is your goals/objectifs? why you want to participate?
0/250
What is your motivation for joining the Program

Expand work potential or skill setsVolunteer or service experienceCommunity developmentPost-secondary experienceOther
How did you hear about this program?*
Requirement
Completion of Application*

I certify that all the information on this form is truthful and correct to the best of my knowledge. I understand that any false or inaccurate information may be grounds for dismissal in the program and I would be required to return to my home. The Informatin in this form will ne held in the confidence by Ruperstland Institute and Katimavik staff and may be used, anonymously, to collect data on the program
Should be Empty:

General Information

Medical Information

Emergency Contact

Education and Work experience

Background information

Motivation

Requirement