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Workshop: Cultivating Space - Women of Colour Leadership 2025
Current
SECTION A - Personal Information
SECTION B - Questionnaire
Complete
First Name
Last Name
Address
Address
City/Town
Province
- Select -
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
Preferred Phone Number
Type of preferred phone number:
- Select -
Cell Phone
Home Phone
Work Phone
Other
Secondary Phone Number
Type of secondary phone number:
- None -
Cell Phone
Home Phone
Work Phone
Other
Personal Email
Job Title
Employer
Work Site Name
HEU Local (if known)
Employment Status
Full-time
Part-time
Casual
Region
North
Interior
Vancouver Coastal (includes PHSA)
Fraser
Vancouver Island
Do you self-identify with any of the following equity groups? (Check all that apply)
LGBTQ2S+
Indigenous
People with Disabilities
Person of Colour
2-Spirit, Woman, or Non-Binary
Young Worker (35 years or younger)
Older Worker (55 years or older)
Prefer not to say
Emergency contact name
Emergency contact phone
Do you have any medical condition(s) or is there anything else that we should be aware of that could impact your ability to participate in this event?
Yes
No
If yes, please briefly explain. (In some cases, a physician's note may be required).
Do you have any accessibility requirements (i.e. ergonomic chair)?
Yes
No
If yes, please briefly explain.
