IMPORTANT INFORMATION – PLEASE READ:

Please follow the below steps to register for the forum:

• Complete the below Registration Form by February 15th 2021.
• An email will automatically be sent to you with your login details. If you don’t receive this email, please contact us.
• Login to your profile – https://forums.experiencescanada.ca/student-profile/
• Upload your submission – Answer the question “what does Reconciliation mean to you?”
  • • We’re looking for inspiration using whatever medium you choose (a written piece (pdf), an artwork (jpeg or png), a video (YouTube, Vimeo or SendVid URL), or video of a performance) that will spark ideas or strategies that could foster greater dialogue and understanding among non-Indigenous and Indigenous young people.
    • You can see examples of submissions from previous forums here: https://forums.experiencescanada.ca/examples/
    • Your submission MUST be uploaded by February 15th to be considered for selection.

Register

Register

First Name *

Last Name *

Preferred Name

Email Address *

Password *

Eight characters minimum One lowercase letter One uppercase letter One number One special character

Gender

Male

Female

Non-binary

Two-Spirit

Gender Fluid

Other:

Phone Number *

Example: 9999999999

Text Contact (Cell Phone)

Example: 9999999999

Address *

City *

Province * Alberta British Columbia Prince Edward Island Manitoba Northwest Territories New Brunswick Nova Scotia Nunavut Ontario Quebec Saskatchewan Newfoundland and Labrador Yukon

Postal Code *

Example: A1A 1A1

Birth Date *

Have you ever participated in an Experiences Canada exchange or forum?

Yes, Specify yearYes, Specify year

No

What language do you want to correspond with us? *

English

French

Name of school you Are currently attending

Name of teacher (if being submitted as part of a class/team project or assignment). Name of youth leader (if being submitted as a part of Duke of Edinburgh/Girl Guides/Scouts/other youth group activity)

Community Group affiliation (if any)

Experiences Canada encourages the participation of all youth regardless of language, culture, or socio-economic status. We collect non-identifying demographic information that is used for evaluation purposes. All responses are kept confidential.

1. Are you a person with a disability?

Yes

No

A person with a long-term physical condition, mental condition, or health problem, who is limited with respect to functions in the home, in school or other activities (e.g. leisure time activities)

2. Do you live in a low-income household?

Yes

No

A person who lives in a household earning less than the Low Income Cutoff as defined by Statistics Canada.

3. Do you identify as a member of a visible minority in Canada?

Yes

No

An individual, other than an Aboriginal person, who is non-Caucasian in race or non-white in colour.

4. Do you identify as Indigenous - that is First Nations (North American Indian), Métis, or Inuit?

Yes

No

A member of a First Nation, a Métis or an Inuit.

Territory:

5. Do you live in a rural or isolated area – that is a community with a population of less than 10,000?

Yes

No

A person who lives in a community with a population less than 10,000

Travel & Other Preferences

What is the nearest major airport to your community?

What distance (in km) are you from this major airport?

Special Travel or Dietary Requirements?

What is your T Shirt Size? * XS S M L XL XXL

*Adult sizes only

How did you hear about Experiences Canada Youth Leadership Forums?

Questionnaire

1. My attachment to Canada is:

Strong

Moderate

Minor

I don't know

2. My knowledge about Canada's diverse history & culture is:

Strong

Moderate

Minor

I don't know

3. My community involvement is:

Strong

Moderate

Minor

I don't know

Communications Options

Users must click YES or NO to the following communications preferences:

Sign Me Up For The Experiences Canada Youth Leadership Forums E-blast?

Yes

No

Send An Email To My Teacher/Group-Leader When I Complete My Submission

Yes

No

Email Address of Teacher/Group Leader

Collection and Use of Personal Information

As the parent/guardian, I hereby give my consent for EXPERIENCES CANADA to collect the personal information required for submission to the EXPERIENCES CANADA Youth Leadership Forums. I understand that this personal information is required for the purposes of selection and program delivery and that it will only be used by EXPERIENCES CANADA or disclosed to select third parties who are acting as suppliers, service providers or who provide funds to EXPERIENCES CANADA and who have agreed to protect the personal information supplied by EXPERIENCES CANADA.

By checking “Yes” I indicate that I freely give my consent to the collection and use of personal information of this participant as set out above. *

Yes

I understand that my child (or myself) may have the opportunity to express himself/herself verbally or in written form, create or appear in photographs and/or video recordings at any point during the EXPERIENCES CANADA Youth Leadership Forum, individually or as part of the group.

Please choose either YES or NO *

Yes, I hereby give EXPERIENCES CANADA, its funders and associated partners, permission to release and/or publish these statements, photographs and/or video recordings for educational and promotional purposes.

No, I do not give EXPERIENCES CANADA, its funders and associated partners, permission to release and/or publish these statements, photographs and/or video recordings for educational and promotional purposes.

Name of participant *

Name of parent/guardian

If under age of majority

Date (today) *

Daytime Phone Number

Example: 9999999999

Email Address of parent / guardian *

If you are human, leave this field blank.