Métis Student Solidarity Network
Student ApplicAnt - informAtionfAcilitAtor eligibility criteriA
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infinite reAch: mArch breAk cAmp
FEBRUARY 10TH, 2014
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pleASe forWArd ApplicAtion toU� Ã�i��>}J�iÌ�Ã�>Ì���°�À}�
for ASSiStAnce
ApplicAtion deAdline
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pleASe forWArd ApplicAtion to: E-mail: [email protected] Fax: 1-613-722-4225
For assistance please call
1-613-798-1488 ext 137 or 1-800-263-4889 ext 137
Métis Student Solidarity Network
Section 1 – informAtion Source
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Student ApplicAnt - informAtion
Section 2 – perSonAl And contAct informAtion
Last name: Given name: Date of birth My Métis community: Gender:F�M F�F
Address During Academic Year (September – April)Street Address
City Province Postal Code Area Code & Telephone #
Permanent/Home Mailing Address (May – August) F Same as above
Street Address
City Province Postal Code Area Code & Telephone #
E-mail Address
Alternate E-mail Address
PLEASE FORWARD APPLICATION TO:
E-mail: [email protected]
Fax: 1-613-722-4225
For assistance please call
1-613-798-1488 ext 137 or 1-800-263-4889 ext 137
Métis Student Solidarity Network
SECTION 3 – EDUCATION
STUDENT APPLICANT - INFORmATION
What is the name of the high school you
are currently attending?
What grade are you currently in? What do you want to study
in the future?
Please provide Letter of Support
Name of reference Position of reference Telephone # Email address
Has anyone in your family
attended college or
university before?
F Yes F No
If yes, have they attended
college or university?
F Yes F No
SECTION 4 – mOTIVATION
In no more than 300 words please explain how you believe the student you have chosen to support will Li�iwÌ�vÀ���>ÌÌi�`��}�Ì�i�Óä£{���w��Ìi�,i>V���>ÀV��Ài>��>�« in the space provided below:
Métis Student Solidarity Network
Section 5 – letter of Support
Student ApplicAnt
Name
E-mail Address
Please identify yourself as one of the following:
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III-V>��>�`�i�>���Ì��[email protected]��À��>Ý�Ì��1-613-722-4225
________________________ ______________Signature of Parent/Guardian Date
Métis Student Solidarity Network
informAtion
AlternAte emergency contAct:
emergency contAct:
medicAl
heAlth informAtion
2014 March Break caMp - medicAl form
School: Grade:
Name:
Home A`dress:
Name: Relationship: Telephone:
Name: Relationship: Telephone:
Health Card Number:
Doctor’s Name : Doctor’s Phone Number:
Under a doctor’s care at present?: F�Yes F�No
If yes, please provide details and note any precautions to be taken:
Will any medications be taken during the program?: F�Yes F�No
If Yes, please specify the name of the medication, dosage and frequency:
Please list any allergies (food, environmental, medication): List any special dietary considerations (vegetarian, religious):
Please indicate whether full participation in activities (outdoors and indoors) is allowed: F�Yes F�No
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________________________ ______________Signature of Parent/Guardian Date
pleASe forWArd ApplicAtion to: E-mail: [email protected] Fax: 1-613-722-4225
For assistance please call
1-613-798-1488 ext 137 or 1-800-263-4889 ext 137
Métis Student Solidarity Network
mArch breAk cAmp (mArch 8-12, 2014)
pArentAl conSent form
________________________ ______________Signature of Parent/Guardian Date
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Métis Student Solidarity Network